creating better living environments for people with … better living environments for people ... 2...

creating better living environments for people with dementia

Dementia is now recognised as the most significant issue facing carers and service providers for older people. This presents many challenges but also new opportunities for us to create better environments and services...

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Introduction 2

Exemplary design for extra care 4

Extra care

Supporting people with memory loss and mild dementia 4– the assisted bathroom 6– the meeting place 6– applied assistive technology 8

Exemplary design for specialist dementia extra care

The cluster model in extra care apartments 10– wayfinding 10– the front door and hall 12– the garden court 12– the lounge/hearth 14– the snug/retreat 14– the kitchen area 16– the shared hub 16

Exemplary design for residential dementia care

Aspects of interior design in dementia care 18– understanding, accommodating and respecting residents’ wishes 20

– the exemplar en-suite room 20

– the exemplar night nurse station 22

– the exemplar shared cooking and eating area 22

Conclusion 24

creating better living environments for people with dementia

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Housing 21 is one of the leading providers of care, health and housing services for people with dementia in the UK. We are committed to improving knowledge and understanding in terms of building and interior design as well as providing care for people with dementia.

Housing 21 has a strong track record as a provider of specialist dementia care services, housing solutions and a reputation for ground-breaking research on dementia. We were the first organisation in the country to offer specialist dementia palliative care services through the Dementia Voice nurse and the first to develop a Korsakoff specific social inclusion service.

The current service portfolio includes the following:Dementia Specialist Extra CareDementia Specialist Residential CareDementia Day ServicesDementia Voice NurseDementia Advisor ServiceDementia Carers TrainingDementia Respite ServicesDementia Community Day Care ServicesDementia Community Support ServicesDementia and Long Term Conditions ServiceDementia and Long Term Conditions Extra Care

Thanks go to:Quattro Design ArchitectsAiveen Interiors

Photography Paul Bullivant and Mark David Hill

introduction

2 creating better living environments for people with dementia creating better living environments for people with dementia 3

The key facts are:

• The average age of people across Housing 21’s retirement housing ranges from 78 (sheltered) to 81 (leasehold). As of October 2010, we had 91 people living in our housing schemes aged over 100. At least half of this group will have dementia. The steepest increase in terms of our customer age profile is the ‘oldest old’ (over 85s) and this rising trend is set to continue.

• According to our last care and wellbeing survey (July 2008) over 7% of residents of sheltered housing were diagnosed with (2.4%) or suspected (5%) of having dementia. Numbers have increased slightly over time and the actual figure is likely to be under-reported.

• In July 2008, data from our care and wellbeing survey showed that in extra care housing, nearly a quarter

of residents had dementia – (12.2% diagnosed and 10% undiagnosed). Again the figure showed an increasing trend and this is likely to be under-reported.

• Whilst we have not attempted a similar customer data audit since July 2008, given that our extra care portfolio has grown significantly, it is likely that at least 800 residents in our extra care schemes and over a thousand in our sheltered schemes are living with dementia.

• Overall it is likely that well over 4,117 of our current customers are living with dementia now and if we achieve our service growth forecasts for the next five years the figure could be well over 10,000 people.

It is therefore not surprising that a number of organisations are highlighting dementia as a priority development area over the next five years. Key to this development will be developing new

innovations within services for people with dementia, including new housing and residential design models.

The National Dementia Strategy, published in 2009, refers to the need for access to housing that supports people with dementia and to assistive technology – both of which are key areas that we are developing at Housing 21.

Housing 21 has a strong track record as a provider of specialist dementia care services, housing solutions and a reputation for ground-breaking research on dementia. This guide is intended to highlight the key issues to consider in the design and management of extra care and residential care for people with dementia.

We have looked at the latest thinking and included descriptions and examples of best practice in dementia building design. Good design can improve the

quality of life as well as reduce stress levels in people with dementia, which in turn brings benefits to their family and carers.

Good design can also maximise a person’s independence, particularly through the careful consideration around orientation, using materials and items of interest to create visual cues.

With older people being the largest users of healthcare services, it is important to recognise the need for specially designed environments to meet their requirements. In the case of dementia design, this includes environments which help to alleviate symptoms rather than aggravate them.

Dementia is one of the greatest challenges facing our society today with rates of dementia set to increase significantly across the country over the next 10 years.

4 creating better living environments for people with dementia

exemplary design for extra care

The design of buildings must reinforce the philosophy of care, so we look for opportunities to bring in lots of daylight and create spaces that are nuturing and that incorporate simple triggers to encourage people to want to socialise with others.

Aspects of extra care design that focus on supporting people with memory loss and mild dementia include:

• The plan should be arranged with short wings of accommodation where up to 10 flats form a natural community within the larger development

• Corridors are arranged to maximise natural light

• Corridors should lead to meaningful destinations, such as a furnished meeting place or snug

• Different colour, texture and furnishing should be used for each wing to support way-finding without the reliance on signage

• The entrance foyer should be of double height feature to achieve a sense of arrival and a glimpse of the scale of the building beyond

• There should be logical progression through the building from public areas through semi-public areas to private areas

• Apartment entrances should be indented from the corridor or internal street to achieve a personal, defensible space at the threshold.

Supporting people with memory loss and mild dementia

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S C A L E D A T E

1 GREAT GEORGE STREET BRISTOL BS1 5RRTEL (0117) 9299672 FAX (0117) 9349000

BEARLAND LODGE GLOS GL1 2HTTEL (01452) 424234 FAX (01452) 383996

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Extra Care Housingand Resource Centre,

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MAR '07

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Extra Care Shared Facilities

Extra Care Flats2B3P (52no.)

EMI Resource Centre

EMI Offices

Sheltered Houses2B3P Chalet Bungalow (10no.)

Extra Care Flats1B2P (8no.)

A 25/5/07 Replace hedge to westernboundary with 2.5m timber screen wall following discussions with LA regarding maintenance.rabRev B: 16.06.09 - Added clarifications and minor amendments to site layout

Cambrian Green Court Extra Care

creating better living environments for people with dementia 5

They should incorporate a dressing table area with perfume bottles, make-up and mirror, soft white towels, a domestic wash hand basin and even candles.

The issue with the assisted bathroom is often the size requirements for the assisted element. One way of getting around this is to translate the assisted bathroom into a spa facility. The context given to the person with dementia is that of professional spa facility, with low level lighting, music and pleasant perfumes. The integration of the spa/bathing experience into the care of the individual can provide the space for a person to receive individual attention in a setting that is designed for renewal, revitalisation and pleasure.

The meeting place


The assisted bathroom facility is an essential element of all extra care schemes. Often it is the only available bathing facility in the building, as the standard design for extra care apartments tends to favour fitting en-suite shower facilities. Yet, often the assisted bathroom is perhaps the most poorly designed space in the extra care setting. They can be unpleasant for all users but particularly for those with dementia. Limited lighting, clinical and cold environments help to create noisy environments for those older people with sensory impairments.

The clinical environment also lacks the contextual cues necessary for an individual with dementia to recognise that they are about to have a bath, which often leads to confusion, fear and anger in some residents.

The bathrooms should be designed to be as welcoming as possible, resembling a domestic bathroom in scale and design.

The assisted bathroom


This should include the creation of stop-off points, to create meaningful walking routes within a building. For people with dementia, these points can give purpose to walking but also opportunities for social interaction. This does not mean that placing a chair in a corridor is a meaningful meeting place; one needs to ask the question as to whether you yourself would feel comfortable, for example, sitting in the middle of a corridor? By adding tea and coffee making facilities, a newspaper rack or a bookcase, you immediately give a context as to why the chairs are there.


The use of assistive technology with people with dementia in extra care facilities is becoming more commonplace. Unfortunately, so too is the use of this technology as a monitoring tool that can disempower the service user. Take the example of an electronic tagging device that triggers on exit from an extra care facility. This alarm can be used to make staff aware that a resident with dementia is leaving the building. It can either prompt a member of staff to walk with them or at a distance at which they can safely observe them and limit risk, which is an empowering response, or they can use it as a way of blocking the resident’s exit from the building.

Within Housing 21, technology is used when it can help deliver care and increase independence. Housing 21’s extra care facilities are fitted with a Tunstall overlay system as standard and devices such as bed-motion sensors,

Applied assistive technology

low level guide lighting to bathrooms, flood sensors, door exit sensors and voice prompting are used based.

These are based on individual need and are fully integrated into the care planning process. Other uses of assistive technology include:

1. Property exit sensor monitors day and night for unusual movements, detects doors left open and links to external lighting

2. Flood detector senses bath, sink or washing machine overflows

3. Natural gas detector and shut off valve will turn off the gas supply if a leak is detected

4. Medication reminder dispenses medication with audible and visual alerts helping both the user and carer

5. Temperature sensor monitors extreme temperatures and unusual changes in temperature

6. Carbon monoxide detector senses unusual levels of CO gas

7. Carer pager alerts carers even when they are away from their usual monitoring location

8. Bed occupancy sensor senses if user has not returned to bed as expected, and can be programmed to switch lights on

9. Enuresis sensor detects moisture in the bed, making physical checks during the night unnecessary

10. Radio frequency identification button provides dignity in care for laundry management

11. ADLife can record usual behaviour patterns and identify when deviations from the norm occur.


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How the benefits of the cluster model of dementia care can be realised using extra care flats


exemplary design for specialist dementia extra care

The central principle behind the design of Housing 21 specialist dementia extra care is to create an environment that is ‘homelike’ but reflects the changing needs of the individual as the dementia progresses. Housing 21 recognises the importance of the integration of architectural, interior and care design in the creation of communities and/or a sense of being at home.

Over the past 17 years or so we have come to understand that good design stems from getting those small details right without losing sight of the overall objective.

Our experience with extra care housing began in the late 1990s and from early 2000 developed into a specialism that has led to extensive experience in the interior design of retirement and care housing projects.

The ethos and specific needs of the residents are translated into an attractive

environment with a welcoming yet protective feel within established project objectives and parameters.

Aspects of extra care interior design that focus on supporting people with mild dementia:

Wayfinding

Helps people with dementia move independently from one place to another. One important objective of the interior design scheme should be to aid people including those with dementia in navigating around the building as independently and as freely as possible.

Effective wayfinding clues:

• Colour coding: colour choice is very important if clues are to be read appropriately.

• Meaningful decision points: where a change in direction (corridor junctions) or levels (lifts & stairs) is required, then design features such as a change of wall

or carpet colours or surface texture, the use of wall pictures or tapestries and sculptures can all aid orientation and correct decisions.

• Seating placed strategically along long corridors for visual recognition and small rest points.

• Furniture placed at end of corridors (corridor never seems to end syndrome) sideboards for rummaging, seating to stop, rest and aid change of direction.

• Strategically place items that specifically indentify the purpose of that room when entered e.g. a bed at first sight on entering a bedroom.

• A simple furniture layout which is logical and consistent to maintain is more easily remembered.

• The use of bright contrasting colours between furniture, flooring and background walls so each can be more easily identified.


Plan of Beeches Manor Specialist Dementia Extra Care


A fundamental design feature of a specialist dementia extra care facility is the requirement to develop smaller communities of people in what are often fairly large buildings.

The research points to communities of between eight to 10 people as the optimum size. One way of identifying these communities is by separating them environmentally by developing clusters of eight to 10 apartments accessed through a single front door and hallway. This door is where the post is delivered, where the professional visitors enter the cluster after ringing the doorbell and where friends and relatives visit.

The design of this entrance as a domestic door, rather than an electric opening sliding door, provides the clear cue to residents that this is their entrance to their home and an entrance by which they have control and a say as to when people visit and, more importantly, when people leave.

The front door and hall

Access to outside space is incredibly important to people with dementia. Space that is subject to the weather, seasonal variations and 24-hour light variations provides people with context in terms of time of day and season.

There is also the sensory experience of being able to place your hands in soil feeling the sensation of the soil between your fingers. However, more importantly, the joy of planting a seed and looking after it through germination and into flower and fruit is life affirming and gives people a reason to get up in the morning.

The garden court provides this, with its open roof that allows the light and elements to flood in, with its raised flower and herb beds and easy access to garden tools and with its availability of chairs and tables, it becomes a central and important activity point.

The garden court



The hearth is the heart of the house, a place where people naturally congregate. The design of Housing 21’s specialist dementia extra care makes this a focal point of the lounge with a flame effect wood burner.

The hearth creates a sense of emotional and physical warmth and comfort for people. It is a place where residents can gather, socialise, drink warm milk and hot chocolate. The lounge also provides opportunity for activity, with bookcases and television access.

The snug or retreat provides the community with a communal quiet space, a place in which one can still be part of the community, but can engage in solitary activity or have a quiet discussion with a friend.

These areas can be designed to provide the context associated with a study, conservatory or den. What is common in these areas is the provision of small groups of seating, books and table top games such as chess, draughts etc.

The lounge/hearth The snug/retreat



The communal kitchen area is a central focus within the cluster. It is the hub around which the life of the cluster revolves. It is a place where family, friends, staff and residents gravitate towards.

The kitchen is designed to be an area of constant activity, with stocked cupboards, fridges and a constant supply of tea and coffee. It is designed to be accessible to everyone.

Including glass-fronted cupboards makes it easy for residents to identify where things are, and the constantly stocked fridge means that they can eat at any point of the day. The kitchen has been designed to mimic a domestic-scale kitchen and to create a welcoming environment.

Using a single dining table and preparing communal meals within the cluster encourages the creation of a

community. Equally, the inclusion of a high chair and toy box makes the area equally accessible to the residents’ grandchildren and encourages intergenerational visiting.

Residents are encouraged to take part fully in the activities of daily living that occur in any household. The familiarity of the kitchen in the preparing, eating and clearing away meals gives purpose to a person’s day.

The communal kitchen area The shared hub


The shared hub has been designed to sit outside of the cluster communities. The role of the shared hub is to provide a focus for activity that involves leaving the cluster.

The hub is designed to be welcoming and is purposely not pristine, with evidence of activity such as paint splatters and clay smears. The hub provides an environment in which to explore different activities from arts and crafts through to discussion groups.


The central principle behind the design of Housing 21 specialist dementia extra care is to create an environment that is ‘homelike’ but reflects the changing needs of the individual as the dementia progresses. Housing 21 recognises the importance of the integration of architectural, interior and care design in the creation of communities and or a sense of being at home.

Dementia care concept living

This promotes and encourages the independence and mobility of people to enable them to do as much for themselves as they can comfortably and safely manage.

Concept living

Clusters of ten flats or bedrooms that create a smaller family environment that should be welcoming and have a homely feel. “A place to call home, that is home”.

The cluster space is generally open plan

so that the kitchen, dining, lounge and toilets can all be clearly seen from within. Each space should be clearly defined and identifiable. Again, specific objects within that space can often define its function, which is important.

Activity rooms such as art / painter studio should display easels, paint pots, paint brushes and lots of art work on walls to help easily convey their use.

Assisted bathrooms are an essential and important area and should be inviting, homely and feel as domestic as possible. Vinyl to bath area only with cosy carpet feel underfoot elsewhere with armchair to assist with undressing, wallpaper, wall lights to give ambiance and attractive furniture for storage.

Key pieces of furniture to embrace and stimulate activities. This could include a traditional writing desk or bureau to encourage writing letters and bookcases to promote browsing and reading.

A bird cage with a canary or a fish tank with lively coloured fish helps to promote a relaxing area and simple company.

Bedroom bedding such as duvet cover, sheets and pillow cases to be in different vivid colours so each item can be clearly seen and help identify layers.

As people get older it can become more and more difficult to get out and about in the community. As more time is spent at home it becomes important to encourage relatives and the general local community into the development to provide interaction with normal everyday life. Good interior design of communal spaces cans greatly aid this integration.

Conservatories and Mediterranean style courtyards can provide fresh air, natural sunlight and plant life, an outdoor garden experience within a safe space.

Aspects of interior design in dementia care

exemplary design for residential dementia care


Shearwater Court (Portsmouth City Council) Dementia Nursing Home finishes plan

Floor finishes/colours

Wall colours


Residential dementia care is provided for people with challenging behaviour due to profound memory loss and end of life nursing. Typically a care home will offer some permanent beds and some respite. As in the lower support models of extra care and dementia specific extra care the focus will be on staff and volunteers encouraged to participate in residents’ lives, building on the skills they have retained rather than focusing on their shortcomings. Groups of en-suite rooms, preferably less than ten, will be clustered around a shared farmhouse kitchen which residents are drawn towards by lighting, sounds and smells.

Each group will have its own identity with a bespoke front door, den for withdrawal, assisted bathroom, sluice and stores. It is preferable to have direct access to an outside space


Understanding, accommodating and respecting residents’ wishes

The exemplar en-suite room

Bedrooms are designed to offer residents privacy and dignity whilst being easy to use for carers. The bedhead will have a view out of the window as well as sight of the toilet through the bathroom door. The furniture will be practical, familiar and easy to use. A wardrobe with glazed doors helps the user select appropriate clothing. Floor coverings need to be easy to mop, a wood effect vinyl plank may look better than a very low pile washable carpet. Furnishings are colour themed for each group to enable ease of identification when there is an infection control incident. The en-suite room will have a fully accessible shower with a half height screen for assisted bathing. The toilet pan has a contrasting seat, lever flush and grab rails to suit the user. The basin has cross head taps. There is no mirror but there is space for shelving to display toiletries. Good lighting levels that can be linked with assistive technology are essential to help people find their way around during the night.


In a traditional care home night nurses will be expected to cover two groups of rooms so their base needs to be pivotally located to enable them to see residents moving around. With improvements in technology, the need to be in one place has reduced and Housing 21 now places a desk in each cluster. This computer work station can double as a place for staff to write up notes and for residents to unlock memories, eg research family history, look at archives.

Subtle clues can help residents remember that it is night time. Opening their room door should not trigger bright lighting to come on but mimic night time conditions and alert a carer, preferably dressed in night wear, to respond.

The exemplar night nurse station The exemplar shared cooking and eating area


This room is the heart of each cluster of rooms and will have the ambience of a farmhouse kitchen where residents, staff and volunteers meet to share meals. A run of kitchen units will encourage participation in food preparation, cooking and clearing away. Washing-up can be a therapeutic activity and need not result in perfectly clean crockery ready to use again.

Dining furniture must be practical, robust and stable in use but need not all be matching, the aim is to create a home like experience where items would have been gathered over many years. Glass fronted cupboards or open shelves make choosing items easy. Likewise, a glass fronted refrigerator is more enabling for residents to help themselves to drinks.

The kitchen area will be open to a lounge with a focal point fireplace, comfortable chairs and probably a large format

television. However it is essential to offer a small den or snug room where those who want to withdraw can find peace and quiet or let off steam. Access to an outdoor space for messy hobbies is desirable.


conclusion

Making adaptations in an extra care facility, for example, makes a huge difference not only to those residents with dementia but to everyone living in the scheme. Small changes, such as creating stop-off points within corridors not only allow people with dementia to engage in meaningful activity but also help residents with mobility problems to navigate longer distances effectively.

We see a strong interconnection between the way in which extra care facilities and specialist dementia units are designed. There is no reason for segregating within extra care facilities, unless there are significant environmental differences between dementia and generic extra care. In Housing 21 our preference is to place a cluster design alongside or attached to the extra care facility, should a specialist dementia extra care component be required.

Our experience is that – if designed well – both extra care facilities that incorporate dementia design and specialist dementia units can offer environments that are suitable for people right through to the end of their lives. It is not a case of one design being better than another, more a case of meeting an individual’s personal preferences.

At Housing 21, we have found that, very often, excellent dementia design equates very closely with more general principles of good design.

The TriangleBaring RoadBeaconsfieldBucks HP9 2NA

0370 192 [email protected]

creating better living environments for people with … better living environments for people ... 2...

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