Designing space for dementia care
Designing space for dementia care

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Designing space for dementia care

2 Disabled people or disabling society?

Professor Mike Oliver (1996) is an academic and disability rights activist who argues that it is society that disables people:

[The social model of disability] does not deny the problem of disability but locates it squarely within society. It is not individual limitations, of whatever kind, which are the cause of the problem but society’s failure to provide appropriate services and adequately ensure the needs of disabled people are fully taken into account in its social organisation.

(Oliver, 1996, p. 32)

The term ‘disability’ includes a range of physical and mental impairments, but a social constructionist approach, like the one that Oliver takes, would argue that society ‘disables’ by labelling people and by perpetuating stereotypical ideas about what a person with a disability might feel, think or do. Further, Oliver argues against the medicalisation and individualisation of disability and for a social model that is political rather than personal, reflecting one of the early mantras of the feminist campaigns of the 1960s and 1970s, i.e. ‘the personal is political’. As noted, one of the criticisms of the social model approach is that it ignores, or at least plays down, the individual experiences of disabled people. Arguably, it is important to take an approach that recognises issues of power and the dangers that are inherent in ‘blaming the victim’, while also recognising individual diversity of needs. However, it is difficult to argue against Bradford (1998) when he writes:

Most disabled people want to live in the community as independently as possible. The extent to which that can be achieved depends to a large extent on the accessibility of the built environment, at home and in public. Few homes are built with any real thought for more complex individual needs of the people who may live or use them.

(Bradford, 1998, p. 79)

Dewsbury et al. (2004) argue:

[M]edical or psychological models … strongly suggest an expert–client relationship in which the expert seeks to cure or at least alleviate the symptoms experienced by the client. The social model, in whatever form, has the great merit of producing an interactionist account of disability, wherein disability is seen as a construction and thus necessarily a responsibility is shared by all parties.

(Dewsbury et al., 2004, p. 156)

Without seeing the wider context, it is difficult to recognise the relationships of power and how they shape experiences as well as the reality of people’s lives and their problems and needs as individuals. The danger lies in losing sight of the individual and generalising to all people, and this can be difficult to reconcile, especially for health and social care providers.

To illustrate the way in which society can be a disabling environment is to recognise the help and support that all people need, regardless of their ability to know where they are and how to find their way. Everywhere you look in public spaces you see signs that tell you what is where. One way to help people to find their way around public spaces, regardless of their abilities, is to use signs, and in the next two activities you explore this further.

Activity 1 Giving directions

Allow about 1 hour

Imagine that you have been appointed to the post of Communication Officer in your local hospital, which has 32 wards and 22 departments. The hospital has a single entrance point. You note that 54 places need to be signposted.

What would you expect to do in terms of physical signage to ensure that people can find their way around? You might want to consider such things as the size of the font, where to put the signs, and at what intervals. Make notes on this or draw some sketches.

Comment

You might find that the more you look into this, the more complex it becomes, and that the sheer number of signs makes it very difficult to achieve and meet the needs of everyone. You might argue that the repetition of signs for places that are a long way away, and signage back to the entrance should be essential, while symbols and landmarks can also be very helpful. In general, signs need to be clear, well-lit and at the right height. Did you consider where to put the signs and how getting the right height could be challenging? Buildings are not always purpose-built and often have to compensate for poor design with imaginative signage. Using ‘catchy’ names rather than those of unfamiliar benefactors or alien medical terms can also be helpful in overcoming poor design features. Do you think some signs benefit staff rather than service users?

Described image
Figure 5 One possible plan for signage in hospital

Activity 2 Essential signs

Allow about 15 minutes

Imagine that having worked out your plan, you are called to meet with your manager to review progress on the project.

What three key principles do you want to communicate as essential features of helping patients and visitors to find their way?

Comment

How do your points compare with the following?

Signs can be more effective if they are:

  • clearly visible
  • translated into key languages
  • colour coded so that different departments can be clearly distinguished
  • consistent in where they are placed so that people know where to look
  • repeated at regular intervals to reassure people that they are on the right track.

The reality is that not everyone can read or make sense of written signs, or has time to read them. In a state of stress, as one often is when visiting a medical setting, written signs can be missed or it might be difficult to concentrate on them. As another example, if you are using the underground in any large city, attempting to read tube station directions when almost everyone seems to know what they are doing can be embarrassing. It is highly likely that people with early-onset dementia and mild to moderate cognitive impairment will have a sense of shame or embarrassment about standing in front of signs for long periods. Symbols are often used on roads and motorways, partly to acknowledge that drivers might not have enough time to read them and partly to make it easy to distinguish destinations. The symbols below are examples of things that are easily recognisable and often internationally recognised.

Described image
From left: © Cihan Ta k n/iStockphoto; © xyno/iStockphoto; © linearcurves/iStockphoto
Figure 6 Examples of signs that use symbols

Activity 3 Recognising diverse needs

Allow about 30 minutes

How would you design signage for people with dementia and what would you need to consider? Provide some examples. For example, you need to recognise that some people with dementia might also be blind and/or deaf.

Comment

You might have found this challenging because of the high level of dependency on visual signs in public buildings. For non-sighted or visually impaired people, some hospitals use talking signs. Indeed, one large UK teaching hospital provides this service in nine different languages. In hospital settings there is a range of tools available to help people to find their way, including the use of volunteers to offer guidance to people who seem to be lost or in need of help, contrasting colours for each floor, department signage in black and white, and accessible and visible information desks.

One student told us:

I work in a hospital that uses coloured lines on the floor to denote departments, which are also repeated on the corridor walls with written overhead signs as well. We also use a system of volunteers to approach people who look lost and in need of help. The most common question that people ask is how far somewhere is.

Reading this made me think about the way in which airports are very clear about how long it takes people to get to departure gates because they want people to board on time. The fines for missing a departure slot cost airlines a lot of money. The information on time is not for the convenience of the customer, but this might be something that you added to your list! However, while the technology for things like talking signs might exist to overcome some of the barriers, not all regions and settings use it.

Poor design can result in compromised care. For example, it might seem necessary to constantly guide people with dementia and not let them find places themselves, or confine them to a space where they won’t get lost or hurt themselves. That is the case whatever the setting. Add to this the potential impact of being admitted to a completely new care setting and not understanding why you are there. Worse still, the place that you are in is confusing to most visitors. These multiple layers can make people with slight disorientation become much more confused. It is thus not surprising that much attention has been paid to the role of architectural design in health and social care (Marshall, 1998). Some providers have recognised the need to compensate for the lack of orientation that can be part of living with dementia (Day et al., 2000). Examples include different types of sensors to detect and monitor where people are, lighting that is triggered by movement to help to prevent falls, alarms that tell people when to take their tablets, and satellite navigational systems for pedestrians. As the population ages, there is an increasingly large industry selling well-designed aids that help people to overcome disability, and the dementia care industry is no exception.

Good design of care settings can also be encouraged through the involvement of service users, but involving people with dementia in the design of care spaces such as residential homes is not always feasible. People with dementia can be marked out as different from ‘normal’ people and are thus not invited to engage with planning of living spaces, and their cognitive impairment might make it very difficult for them to do so. In what follows you explore key aspects of creating spaces that allow for a better quality of life for people with dementia.

In the UK, some care homes have been designed for people with dementia, incorporating features of good design, and in the next activity you see two examples of such good design. One care home was purpose-built, and the other was adapted for dementia care.

In 2009, the Department of Health commissioned the King’s Fund to develop programmes called ‘Enhancing the healing environment’ (EHE) that would improve the experiences of people with dementia as part of the National Dementia Strategy. At the time of writing (2012), projects from 23 teams of mental health, acute and community trusts have shown how changes to lighting and floor coverings, and improved wayfinding, have a significant impact. In the mental health trusts they reported a reduction in the number of falls, violent incidents and aggressive behaviour, reducing the need for the use of antipsychotic drugs (King’s Fund, 2011).

Activity 4 Good design in practice

Allow about 30 minutes

Watch the videos below about two care homes, Elmhurst and The Lodge, in which the care staff talk about the difference that the design has made to the experience of being in a care home. Note how the principles of good design have been used and consider the following questions:

  • What difference has the design made to the lives of the residents?
  • What do the staff and family have to say about the difference that the design has made?
  • Note what it is possible to do on a low budget.
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Transcript: Video 1 Elmhurst

Video 1 Elmhurst

Elmhurst Residential Care Home, Ulverston, Cumbria

Elmhurst was purpose built in 1983, to accommodate forty physically frail people. Now demand has shifted. Thirty of today’s residents have some degree of dementia. But the original building wasn’t designed to be dementia-friendly.

Beckside was the first wing to incorporate dementia-friendly design features.

Jayne Allonby, Registered Manager
One of our problems here was keeping the home odour-free and so we looked at the flooring initially. We looked at something that was homely, that was serviceable, that was practical, that was easy for people with mobility issues to move around on, and so we came up with the laminate flooring. From choosing that, then that really sort of impacted on how everything else went, because once you started to choose one flooring, then you can’t have a great difference between any other flooring, so what went through the corridors had to mingle in with the bedrooms, the bathrooms and the lounge areas, so that was where we started really. From there we sort of worked up. We looked at contrasting paintwork, plain papers, contrasting doorframes, skirting boards and things like that.
Throughout the course what’s stood out to me is the lighting. The lighting’s just been phenomenal and what a difference, 'cos they were really dark corridors before, you know, people couldn’t find their way very well. It just seemed such a dull place, and the lighting has just absolutely lifted it.

Residents’ front doors now have contrasting designs and colours, which aid recognition. Doors to utility rooms are painted to blend in with the walls. Bathroom and toilet doors are painted yellow, so they really stand out.

Jayne Allonby
We did have a long debate about the colours of the toilet seats because they should be a big contrast to your white seats, so we went through blacks, blues. We found that the last colour people retain is red so the County Council made a decision that we would have red, and I had this vision of red and white just looking absolutely horrendous really, and then they said we had to edge it with black tiles, and you just got this vision of your red, white and black and oh, it’s going to look really awful. But when we accessorised them with the different towels and the pictures, and things, it all seemed to come together and they do look absolutely, I mean I don’t think that they’d look, apart from you’ve got to have obviously the rails and everything else, which were co-ordinated with the seats. I think they look really nice and sort of personal now.

Residents had some choice over the colours of wallpaper and furnishings.

Jayne Allonby
We had a selection of papers and we chose what contrasted with those. So we said if you would like this paper, then you’ll need to either have this chair or this chair, this curtain or that commode to contrast. We could say yes, you can have a choice of this, this and this, but that is a restricted choice really.
Susan Garnett, Support Worker
It’s very important that the residents did get involved with the choosing of the colour schemes and the door fronts and things because this is their home, and they’ve got to feel as if they really belong here.

The refurbished rooms incorporate dementia-friendly furniture and fittings.

Relative
What are we going to put on today? Do you think we need a coat?
I think the refitting has had a very positive impact on Mum. She seems a lot calmer and happier than she was. She likes the effect of being able to see into her wardrobes and the lights coming on as she goes towards them. With the old wardrobes it was a bit difficult for her to see her clothes. Now she can have more of a choice herself, and she likes her drawers, being able to see into the drawers as well.

The mirror over the sink can be hidden behind dementia-friendly wooden doors. And each of the rooms is fitted with a range of assistive technologies.

Relative
The alarm on the door is good, it’s good for me as well to know that in the night when she is up that somebody’s aware that she’s up and about, because when there’s limited staff on in the evenings it’s quite worrying that knowing she wanders, if she was to get up and fall or something, at least people know that she’s out and about, and walking round the course.

When residents are out and about, there’s plenty for them to look at.

Resident
It’s nice looking in here. There’s a record, look. James Oliver. 29 King Street, Ulverston. Reminds me of when I was younger.
Carer
Who recognises this tub? Margaret? Oxo cube. Wouldn’t like to think how old that is. I think it lifts up at the front, Margaret. That’s it.

Communal spaces now feel much more homely and welcoming.

Resident
Oxo cubes.
Carer
Yeah. Use them in your cooking. Advertising postcards.
Jayne Allonby
The key changes in the lounge area were, again, the chairs contrasting with the curtains, and the other big thing was the fireplace, so to create that sort of more homely lounge-type setting was to put a fireplace in.
The refurb to the kitchen, that was a really big thing, to have the glass-fronted cabinets, everybody could find things a lot easier, the fridge so you could see what was in the fridge.

A lot of consideration was given to the colour of the crockery.

Eventually we came up with blue because we had yet to find a food that was blue really, and that really did, people were eating better, they could see the food a lot clearer. People’s weight was increasing as well. We realised that the waste of food had dramatically reduced really since this and, not only that, people were a lot more independent at eating as well.
Susan Garnett
I think with the enhancement of the crockery, and the whole setting and surrounds, mealtimes now really are a lovely time of the day, and there’s a lot of conversation and, you know, you learn so much about them and their lives.

Even the garden has been transformed, making it much more dementia-friendly.

Carer
You’ll get me into trouble, you will. I’ve got you.
Resident
She knows what I’m doing.
Jayne Allonby
We’ve got now an area outside where we can all spend time together, whether it be having afternoon tea or games, or whatever, but it’s something other than being in the same lounge. It’s an outside area that we do really use and people really enjoy.
It has to be obviously accessible for all, so we had to look at removing all the raised kerbs that were in there, creating a wheelchair-accessible pathway through. We needed to look at raised beds, so even people that weren’t able to walk could actually still participate in picking the herbs. It looks at all the senses really, so when you’re out there, you know, you can smell the herbs, you can hear the birds, hear the wind chimes. And you’ll often find in the summer the door’s always propped open, and people’ll go out and they’ll come back in, and say oh, the bird seed needs topping up, and so people have really sort of embraced the garden.
Susan Garnett
Joe, tea or coffee, love? Tea or coffee?
The renovation and the improvements on the unit have made a much more relaxed environment. The residents are much more relaxed as well, and you seem to get a better relationship with them.
Carer
You did your netball as well, didn’t you?
Susan Garnett
You just feel like it’s one big family really.
Jayne Allonby
I think the residents are really happy and the key thing for them is they get up in the morning and they’ll say what they want to do now. People are really telling us what they want from life now which is very good.
During the refurbishment it was very difficult, particularly for some individuals. Because we couldn’t empty the unit, people were coming off the unit in the morning when the contractors arrived, they were eating their meals throughout the building, spending the day throughout the building in areas that they weren’t particularly comfortable in, or didn’t want to be in, and when they saw things had been taken up, like their flooring, do you know what I mean, obviously that caused some level of discomfort. However, as they saw things progressing, I think that sort of, it made up for the disruption really, so as they saw the new kitchen going in, and we tried to involve people, so as things were happening we’d take them back to the unit that night and look, look what the workmen have done, we’ve managed to achieve this today and it’s going to look so much better, and so we tried to obviously give as much reassurance as we could.
I think the biggest thing was when the furniture was being delivered, the furniture was delayed in the delivery, and so we’d emptied everybody’s cupboards and wardrobes onto the beds and that, you know, people then, what are you doing, are you packing my goods, are you, you know, are you throwing me out, what’s happening? You know, until the actual new furniture came and we said look, we’ve got new furniture, we’re going to put everything back, and it’s all going to be all right so, yeah, we did have some difficulties there.
I’ve noticed that the staff now use their time differently in that, because of the signage and everything else, people are more independent so they’ll now maybe use the toilet independently, they way-find a lot easier, they’ll undertake tasks independently, setting the tables, various things, so obviously that’s impacted on the staff time that’s available to spend with people, either on a one-to-one or in a group setting, to undertake activities.
If I look at the confidence levels of people, and the reduction in aggressive incidents, I think it’s phenomenal really, and I think to walk onto the unit you do get the feeling that people are very happy to be here, and I think that they have a very fulfilling life, and it’s very rare that people will be down or upset, or we can soon get round it. Yeah, I mean I just think you only just need to spend some time on there to get that feeling of, you know, we’re happy and we’re confident, and we love life, and we’re going to do this and we’re going to do that.
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Transcript: Video 2 The Lodge

Video 2 The Lodge

Buckshaw Retirement Village, Chorley, Lancs

The Lodge is a purpose-built residential and nursing home, designed for dementia care.

Lorraine Haining, Head of Dementia Services
The main feature really is the shape of the building. It’s been built in a triangular shape so that it offers people the opportunity to walk right through the building. In the centre of our triangle we have a fantastic open plan garden space which is very secure, but it also offers people the opportunity to go out into the garden and use it independently. We have two communities on our ground floor and two communities on our upper floor, and in the centre of that we have a place where everybody comes together, called the Market Square, and that’s really about people joining together to enjoy life and, you know, to occupy themselves.

Wide, well-lit corridors are central to the dementia-friendly design.

We try to use natural light where we can. All round the outside of the building the windows are down to the floor so that, you know, anything that comes through the daylight is the best that we can get it, but the corridors down the middle of the communities don’t have any natural light, but we have them very well lit so that people can see, you know, where they’re going and they can see what’s around them, if you like. The space in the corridors as well, there’s sometimes they’re eight feet wide so it allows people to pass without any interactions. People often have spatial awareness issues that are in our nursing communities so they might not move out of the way when somebody comes, or they might walk into people so, because of the space there, we avoid most of those conflicts.
Lucy Ewbank, Care Assistant
When a resident gets agitated we often take them down the corridors because it’s a quiet place usually, you know just to have a walk down, and they have a sit down where like the birds are, and just sit in a different room. And it’s more quiet, and you can talk to them more easily if you just take them out of the noise and just sit them down somewhere quiet. It’s so much better, to just get through to them and calm them down, and then take them back and they’re so much more relaxed.
Lorraine Haining
We’ve tried to go for plain coloured carpets, we’ve not got anything that’s got a pattern on it, and we’ve tried to run that through the building, you know, particularly in the communal areas. We have gone for some wooden flooring in the dining area, really for cleanliness reasons, and we’ve tried to minimise the connection between those two. We had silver gripper bars originally separating the two areas. However, they were actually, people were finding them quite a hazard really. People were stepping over them, thinking it was a step up, so we actually did a little bit of research and we found that the gold-coloured gripper bars were less reflective, so we’ve actually replaced them, and people are having less problems with that. We very rarely find people trying to step up over it now.
Although we have open plan areas each space is very distinct so you still know it’s a dining room, you still know it’s a lounge, you still know it’s an activity area. There are open plan book spaces between each area to make it distinct, but that then offers cues to people who are maybe sitting in the lounge, they see something happening in the activity area, and then they can actually, that draws them into the activities. So people actually can see all around them what’s happening.
Lucy Ewbank
It’s brilliant to see what’s going on around you, and to make sure that, you know, the residents are safe. We can look after one resident but while we’re looking after one we can keep an eye on the rest of them, so that’s brilliant.
Lorraine Haining
There is some evidence to show that people with dementia don’t do well in an enclosed space with closed doors ‘cos they don’t always get up and look out, whereas if you actually have an open plan space people will actually get up and move into areas. It’s like visual cues so that they actually engage and interact with what’s happening in the environment.

Good design is not only about continuity, it’s also about contrast.

Lorraine Haining
Any toilet area in the whole of The Lodge has a bright yellow door. It’s just a colour cue that we find actually helps quite a lot of people with dementia. It doesn’t work for everybody but it does work for quite a few people, and we find it maintains independence and it also preserves dignity 'cos people can then find the toilet quite easy.
In relation to doors that we don’t want people to use, like the sluice, we colour them the same as the natural walls that so it doesn’t draw people towards that. Everybody has their own front door, just like in an apartment block really. What we’ve done is we’ve sourced a different colour for every single apartment door in the building, and that was no mean feat. They also have a number plate on it that’s easy to see, it stands out, and some people have also, they’ve got little way-finders so they have little pots or things outside their front door, like you would have at home. When they see the little pot or the umbrella stand they remember that that’s where they live.
Lucy Ewbank
For the residents to find their own way to their apartment is really good because their independence is boosted again, you know. They found their own room with their own furniture, with their own toiletries and stuff, their own clothes.
Lucy (to residents)
Do you want a drink or anything?
Resident
I’ll have tea. (To wife) Do you want tea?
Lucy Ewbank
Not the strong stuff.
Lorraine Haining
The first thing that’s different about The Lodge is that people have an apartment, rather than just a bedroom. In a traditional care home you get one room, if you’re lucky an en suite, but here you have a little apartment, it’s a home from home, you have your lounge area, you have your bedroom area, you have a lovely en suite shower room, and you have a little kitchen area, so it is really a home from home, rather than just a bedroom.
Eileen, resident
I’m very lucky here. I’ve got a big space, you know, I’ve got a biggish bedroom, living room, toilet, everything, drawers galore, cooker, fridge, freezer. There’s nothing I don’t want.

And everything has been designed to be dementia-friendly.

Lorraine Haining
We’ve got glass-fronted cupboards in all the kitchens so that people can see what’s in them. It helps people remember where things are and access things without getting frustrated. We’ve even got a glass-fronted fridge which is really helpful. It reminds people that they’ve got juice and things to eat, so it encourages people to keep their nutrition up, and particularly their fluid balance. Families will often leave juice and, you know, cartons of yogurt and things like that in for the residents, so again it’s like a home from home rather than having a communal share, or have to wait till somebody provides you with something.
In the toilets we make sure that we’ve got like dark-coloured toilet seats so people can actually see the toilet, where it is, and they can manage to get sat on the toilet without any problems. We tend to find if you have a white toilet with a white floor, and a white toilet seat, people often don’t see it. They often lose their ability for 3D vision and they can’t distinguish where the toilet is in that environment. And also the grab rails and everything are contrasting colours to the tiles so that people can see them, so they’re encouraged to use them then.
Lucy Ewbank
The design helps independence in a way that they feel more like they can do things on their own, so they’ve got the toilet, they’ve got the shower, it’s easy to turn on, it’s easy to turn off. The shower chair is easy for them to put away. The towels are there so that they can get out of the shower and get the towels themselves and then, obviously, the door is yellow so they can see where to get out from.
Lorraine Haining
We’ve got features like, for instance we have claw-handled taps on the kitchen and in the bathroom. We had some discussion with infection control around that, who would have preferred us to have the traditional hospital-type taps where people don’t have to touch them. However, we feel that people with dementia might not recognise that at some point in their journey, and we would rather have people washing their hands than not using them because they don’t know how to. So we had that discussion with them around that and eventually they agreed that, you know, that that would be a feature we could put in, and that has worked really well. We’ve never really had any issues around that.
People are actively encouraged to bring in their own personal belongings to make it very much their own apartment because, obviously, they live there, it’s their home, so we actively encourage that.
Relative (to resident)
Do you remember wearing this?
Resident
Yes.
Relative
Would you fit into it now?
Resident
No.
Relative
Nor would I.
Lucy Ewbank
It makes them feel more at home, so if they want their own chair or their own, like, pictures hung up on the wall, or their own TV, things from home that signify that they are home in a way, so they can just do what they want in their apartment. They can stay there as long as they like or they can come out if they want to.
Margaret, relative
The apartments look out onto the main avenue of the new Buckshaw Village which is tree-lined, and Dad loves trees, so they see the change all the seasons. They can tell the time of day with the amount of traffic, see schoolchildren going past, so there’s always something of interest out of the window.
Eileen, resident
That’s the big thing about this building. I never feel enclosed, you know, even downstairs, as you move around there’s always plenty of space, and something going on, you know, it’s lovely.

The focal point of The Lodge is the two storey Market Square.

Carer
Morning.
Becky Reynolds, Activities and Day Care Team Leader
I run the Breakfast Club which is open from half-nine till half-eleven. It gives all the staff the chance, you know, to bring different residents to the Breakfast Club for their breakfast, instead of having their breakfast on the communities. There’s loads of different benefits from it because it’s a good way of the residents socialising. Some of the residents like just coming up because it’s a bit quieter, and they can have a cup of tea and read the newspaper in a corner. Some residents like coming up because they get to see other people that they don’t usually see on a regular basis. And it also helps the staff as well, because if they bring a group of people up that may be up early, and maybe by nine o’clock are getting a little bit restless, by bringing them into a different environment they feel more settled, which then gives the staff more chance to crack on with getting the other residents up that are still on the community.
The café not only gets used just for Breakfast Club, you can use it for, you know, if there’s any parties that we celebrate, families use it if they want to do a celebration with their loved one, and they don’t want to use it in the community, they’ll have the café, you know, for the day.
There’s the bakery which is also, do you know like, classed as our family kitchen. So last Christmas a family member lived abroad and they came over and they missed Christmas, so in the New Year they came, and they brought the turkey and all the trimmings, and actually cooked the whole Christmas dinner in the bakery, and then all the family came and they had it in the café, so that was really nice.
We’ve got the cinema which we use, obviously, for when we have our film matinees, but we also use it for our movement to music, where we put the chairs all round in a circle, and do that for movement to music.
We have a hairdresser that comes in every Thursday, and the residents can book in to come and have their hair done. It doesn’t have to be just that the hairdresser comes in. The staff can, rather than washing the resident’s hair on the communities, might bring the resident up here and just have a bit of one-to-one time and wash and dry their hair up here.
Lorraine Haining
The Market Square is a fantastic feature but we’re still learning as we go about how to best use it. I think we’re starting to bring people in from outside to use the Market Square. We’ve now got a mother and toddler group that’s running and that’s helped us with inter-generational gap, and it’s helped us reduce stigma, but I think there’s a lot more we can do, so we’re working with schools, we’re working with the local primary care trust in relation to bringing in carers so that we can do some education, so I think there’s a lot more we can do with the Market Square. I think we’ve only just touched the tip of the iceberg about how to use that to its best advantage.

The garden serves The Lodge’s residential and nursing communities.

Garuth Chalfont, consultant in dementia care design
When I first came here this was one big triangular-shaped garden. Since then we’ve had residents come in with different levels of ability and different levels of need. The first thing right off the bat was that we needed to have two gardens. One big garden for everyone didn’t work for everyone. The problem was that we had people coming from one side coming across into another community, mixing with people with different needs, and it created a bit of difficulty, so then staff would keep the door locked. Now the doors are all open. That’s a main criteria for the design of a garden, is it’s got to be an open door policy. So you have to design it in such a way that the staff can leave the door unlocked, and people can independently use it, or they can use it supervised.
When you walk into a garden a person with dementia needs to have an idea of what can possibly happen, and what they can do. The message from the landscape and from the design is not that it’s an institution, but it’s a place that is user-friendly and you’re encouraged to engage and do things, and so I think that if you set the tone in the environment that this is some place where anything that you see, you’re welcome to get on and do it, that’s the sort of message that the space really has to put across.
You need to make sure that the environment enables people to do as much as possible for themselves. You’ve got to have a productive garden and that’s one thing that was not here, and that’s something that I’ve changed. I’ve got fruit trees, I’ve got rhubarb. It’s important to put things in that people can go out, pick, bring in and do something with.
Lucy Ewbank
I think it was last month we made rhubarb custard where the residents picked the rhubarb out and then they cut it, washed it and cooked it, and they ate it for their supper, so that was really good to do.
Garuth Chalfont
If it’s not meaningful for them they won’t come out, you know, they’ll come out, look around and go back in, but if there’s something for them to do, that they’ve taken some ownership over, then that’s crucial. We have animals here so, obviously, if you’re outside and you’ve got animals, then that’s something that needs your TLC. You need to pay attention to them, and a lot of the residents do get involved. We have a rota and then people come down and take care of the rabbits, feed them, water them, clean out the bedding, and just basically pet them and cuddle them, which is very good. Animal-assisted therapy, I wholeheartedly agree with that.

Colour and contrast are important elements of dementia-friendly garden design.

Garuth Chalfont
The colour and the contrast comes from nature. It is helpful just because the eye ages, and the eye doesn’t see certain colours, that you think about the colours of the plants, and you’ll put a cluster of plants together, so that that person can actually see the flower, rather than a bit here and a bit there.

And careful consideration was given to the continuity of the paving.

Garuth Chalfont
You do still need a way to walk your way through the garden to bring you back basically from where you started, so that’s one of the basic design criterias that you’ll always see in a book, right, you need a circular route. But that doesn’t mean it needs to be a race track, and it doesn’t mean it needs to be all exactly uniform, so I work with a hierarchy of paving. We’ve got wide areas, we’ve not narrow areas, and when you walk into the narrow areas that would cause you to slow down and to have a look, and so those narrower areas are places that have lots of interesting, rich planting along both sides.
Lucy Ewbank
And then you’ve got benches all the way around the garden so if they get tired halfway walking round they can just sit down and relax. And then you’ve got an open green area where they can just throw a ball or play football, or whatever they want, they can do.
Resident
Right, are you ready? That one, right there.
Carer
Nearly.
Garuth Chalfont
Because I had to divide it in half, I also took the opportunity to build a very interesting and permeable connection between the two. So I’ve got white picket fence and I’ve got some trellis, and I’ve got a raised bed, and this is all sort of higgledy-piggledy, so that it’s interesting and you go over there and you have a look at it, and you can also look through to the other side, and we have some interesting talking across the fence to the neighbour, sort of interactions that can occur, and if you had just thought we need to divide the garden in half, boom, just put in a dead straight fence that no-one can see through, you’re actually creating all sorts of psychological, not good. If you look out there you would feel trapped.
People with dementia can develop new interests, and I think that actually the value of nature is to provide the opportunity for creativity in a way that it hasn’t been done before. I mean it’s, it’s not rocket science to make a really good garden for people with dementia.
Lorraine Haining
The biggest strength I think that we’ve found in the building is the space, you know we’ve found, and particularly with people with challenging behaviour, which is three-quarters of our population in The Lodge, we have found that that has really had a huge impact on their quality of life, and that’s been, you know, very, that’s, we’ve noticed that change very quickly. You know, they’ve come in from hospital with a challenging behaviour history which has been fairly recent, and sometimes within, you know, a week or two, we see a massive change in that person’s behaviour because they’ve got space to move around, they’ve got a sense of freedom, 'cos quite often when people move into a care home, if it’s small and it’s oppressive, people want to get out, so that sometimes can cause the challenging behaviour. Whereas here, because we’ve got all the space and people can wander freely, and they can get out of a situation and move somewhere else, they can get time on their own if they don’t want to be with a group, we find that the challenging behaviour reduces dramatically.
Becky Reynolds
Because the rooms and the space is so big you can have different things going on, with different groups of residents, without it causing an issue. I have to say I haven’t known of one incident that there’s been anything of aggression in the Market Square, and I’m convinced that’s because of the space.
Lorraine Haining
What we find is that there are slight differences in how people use the communities. We find in the residential units, for instance, the residents there often use their apartments a lot more. They spend a lot more time in there and whereas, in the nursing communities, people tend to spend a lot more time in the communal areas, so there’s a difference there, I think, in how people use it.
Lucy Ewbank
The overall design is just amazing. The way that the residents can just go off in their own way and do what they want is just brilliant, where you have your separate rooms and your benches and, you know, they can go to their own apartments, it’s their own place.
Lorraine Haining
We’re commissioned by the PCT who are delighted with the outcomes of the people that they placed here, in relation to that reduction in challenging behaviour. We’ve also been able to reduce the use of antipsychotic medication and we believe that the design of the place and the space has had a huge impact on that.
Garuth Chalfont
If a person is anxious and worried, and sad or really confused, then the most beneficial thing for that person is to get outside for a minute and focus on something that’s beautiful, that’s natural, that may be very sensory, and it takes your mind off of what was worrying you. If a person’s very angry, and I know this from some folks that I’ve seen, if you’re very angry, go for a walk around the garden and it, like, changes the air in your head. It brings you to a much different place. You’re in a happier place and all of a sudden that anxiety is not the main thing in your life, because you’ve remembered that you’re connected to the world, and the world is changing constantly, beautiful and interesting, and there’s something going on. So it takes the focus from that person off of their own worries, and puts it onto something that could be very creative.
Lorraine Haining
The limitations we’ve had is we opened residential community first and we put that on the ground floor. If we were going to be doing it again, we would actually have the residents with nursing needs on the ground floor 'cos they have more need to get outside in the open space. I think the residential residents, it’s easier for them to come down on their own and access the open space, whereas it’s harder for the nursing residents, so we would have them on the ground floor if we were doing it again.
You try your best to fit every dementia-friendly design in that you can, but you can’t always get it absolutely perfect.
End transcript: Video 2 The Lodge
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Video 2 The Lodge
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Comment

The two videos show the difference that the design features have made and illustrate how good design affects quality of life for people with dementia. It’s clear, too, that the impact of the environment on care staff is an important aspect of giving good quality care, as noted also by Barnes and the Design in Caring Environments Study Group (2002).

For people with dementia, being lost in time and space might be an everyday experience.

It can be very distressing to be in your own home and not recognise the rooms and layout in the same way. The key principles of the design of space apply equally to domestic settings, . Most people in the earlier stages of dementia live in a home setting, either in their own home or with family members.

Imagine that you have a family member coming to stay with you who has early-onset dementia and is no longer able to live independently. How would you be able to adapt your home? What features are relatively easy to use, and what constraints might you have in adapting a domestic home without major structural changes? This is the focus of the final activity.

Activity 5 Putting design into practice

Allow about 1 hour 30 minutes

In the figure below, you are given two spaces to design – a bedroom and a bathroom. Apply the principles that you have learned in this free course to the design of these spaces for someone with dementia. Make notes on any adaptations and your reasons for including them.

You should imagine that you will present what you have done to either colleagues with whom you work or a support group for carers of people with dementia.

Described image
Figure 7 Bedroom and bathroom for adaptation

Comment

This activity is designed to help you to apply the principles to a real setting. It is also hoped that if you work in a care setting, this is something that could be used in practice, at least as an item for discussion. The small-scale technologies that exist can promote independence for people with dementia. These include such things as electronic tracking devices to prevent people from getting lost, simple communication devices, water-level alarms for baths and sinks, talking labels and touch-screen technologies. Indeed, there are many hundreds of types of small-scale technologies aimed at enhancing independent living for people with dementia.

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