Experts from the worlds of care home design, specification, research and operators, discuss the development of a fit for purpose dementia design framework in a roundtable sponsored by Forbo Flooring Systems
CHP: What is your assessment of the current guidelines for care home design and how they meet the needs of care home designers and providers?
Lesley Palmer (LP), Chief Architect, Dementia Services Development Centre (DSDC): I have written a few design guides both for children with autism and people with dementia and for general housing. All I can say with any certainty today is you can write design guides but you cannot guarantee that people are going to read them. The dementia design principles came out 10 years ago and the research that underpinned them came out 18 years ago and still we don’t see architects engaging with them. We don’t see students of architecture learning about how to design for people with neuro divergent conditions. All the accreditation that we have at the moment on building environments focuses entirely on environmental performance and not on mental health and wellbeing. The industry doesn’t really accept qualitative measures such as someone’s quality of life over the quantitative, which is the environmental performance of the building. One of the challenges we have as a centre is just getting our voice out there.
It still surprises me that we don’t have this uptake because it’s evidence-based design and quite often when we take it to the industry we are met with the response of ‘show us that it works’. I don’t think that is a reluctance, it’s just that it is so multi-faceted, there are so many regulations that you have to comply with that unless it is mandatory it is unlikely it’s going to be taken up.
We are aware that there are many guidelines out there on dementia design in the market. Some are those are not evidence-based. Some are incorrect. It’s quite hard to get our voice heard when we are working with the commercial sector with a commercial agenda which isn’t underpinned by evidence-based research. We are looking for an industry that starts to accept this. Because the construction industry is entirely driven by profit and the need to meet the minimum performance requirements, unless there is something that is brought into play to say you have to achieve this then it’s very unlikely that is going to be taken up by the majority.
CHP: is the cost of meeting dementia design requirements a barrier to compliance?
LP: It can be but if you adopt dementia design principles from the outset then the cost is nominal to the project. The principles aren’t looking for specific materials or specific design requirements. It’s really just understanding the interfaces between different components of different designs.
CHP: How does DSDC’s accreditation system work with Forbo and other suppliers?
LP: We are working with a lot of flooring manufacturers throughout the UK, including suppliers of sanitary products and profiling beds – the more the better because then we start to have rooms that have several products that are all complementary. Forbo Flooring came for a full day’s training on dementia. We talked through how we accredited the product. There’s a core group of researchers, designers and nurses who work together to achieve consensus on whether a product is dementia friendly. We blind review several of the products to see if they have parity on scoring. It’s quite a rigorous process.
Mark Jackson (MJ), Key Account Manager, Forbo Flooring Systems: We started to get a lot of requests from clients and we wanted to do something to help improve the level of dementia design within refurbished buildings.
Julie Dempster (JD), Marketing Manager, Forbo Flooring Systems: When we first started searching for dementia design guidelines, we found quite a bit of conflicting information and so contacted DSDC for advice. We wanted to understand how appropriate our existing portfolio of products, regularly used within the care sector, were in terms of creating dementia inclusive interiors.
Amanda Cunningham (AC), Chief Operating Office, Four Seasons: In terms of procurement, Four Seasons has a dementia care framework. We refer to the Department of Health in Victoria, Australia from 2015. We also consult with the King’s Fund and the DSDC. We look at the layout of the building because if something is purpose-built you start with a new build and it shouldn’t have much financial impact. But when you consider how many new build care homes are being built at the moment, they’re not as prevalent as they were historically, so many of the providers are looking at current environments and how they can be adapted effectively. When it comes to cost, with a new build it is a little bit easier. When it’s an old build, it could be even just the size of the corridors that could be an issue. One of the key things for providers is to look at service diversification that could be led by the actual builder rather than look at diversification where the corridors are too narrow and people can’t pass each other, or if it’s where people who use some sort of adaptation would struggle with the corridors. Having the right people out there who can provide the right kind of equipment is essential.
JD: Even though the DSDC guidelines had been available for a long time, we were still being regularly asked to confirm what specific flooring finishes were suitable for dementia design, so for us independent product accreditation was an important step forward; the aim being to take an element of worry away from care providers about selecting the ‘right’ product.
LP: One of the reasons we developed the product accreditation is around the restructuring of evidence. As a practicing architect, if I were to specify a toilet, I would be looking at a hundred different kinds of toilet and thinking about the size of the toilet, the colour of the toilet seat and even the plumbing systems. If I have a client who has a very specific need such as contrast or height or the flush mechanism it needs, really what I need is information directed to me at the point I’m specifying. We realised it is unrealistic for us to expect architects to read six peer review articles and conclude which toilet was the best, so we saw working with manufacturers as the key way for us to get the information out at that point of contact. That gives clients and specifiers comfort that when they go to a product repository that data is there and they can choose with confidence.
What is fascinating in the journey that we are making with Forbo is we have found that we were having conversations about potential new products that I don’t think either of us would ever have considered without that synergy of the manufacturer on products and processes and us on understanding design.
JD: Having worked with DSDC for over three years now, we have been feeding back the key dementia design principles into our product development process. However, the key point for care providers to remember is that our accredited flooring must still be within 30 Light Reflectance Values (LRV) steps of other critical surfaces, so we are very proactive in communicating the DSDC guidelines to be used alongside the accreditation scheme.
AC: Obviously we are very resident focused. We are all about outcomes being very person centred. During the process that you went through did you actually involve anyone who has a dementia diagnosis or visual impairment? There are lots of people who now live us who have early onset dementia and who are involved in a lot of activities.
LP: You make a really good point and that’s about co-production which is now a key element in our research. We didn’t use this on product accreditation because what we were doing was working with the research guidance that had been established by research undertaken with people living with dementia. The faculty does have a number of research projects in co-production and one of those, for example, is around neighbourhoods and the public realm.
CHP: Sam, would you to like to say something about the guidelines you have been developing with Bupa?
Samantha Ryding (SR), Senior Designer with Bupa care home designer, Lusted Green: Initially they are focused on the interior guidelines in terms of what fixtures and fittings we are putting in with a focus on dementia. For us it’s about being inclusive across the board. When we were looking at research into dementia design we just found bad examples of how other people had done it. It’s difficult to sift through that information and know what the best thing to do is. Of course we have an interest in how it looks aesthetically as well. Care homes and providers are now wanting to have a more aesthetically pleasing and homely look rather than being institutional. We are looking at how to include this within the overall interior design of the home as well as being suitable for people living in a dementia environment. It would be really good to have some clear guidance that we can focus on to look at in products as well as from the aesthetics point of view.
Rebecca Morgan (RM), Designer with Bupa care home designer, Lusted Green: We are looking at how to try to find the right balance between aesthetics and being fit for purpose.
AC: Age is a key thing as well because when you look at the demographics you know there is going to be a massive influx of people living with dementia but we are not talking about people from the Vera Lynn era. It’s difficult to cater for people living together with different tastes and blending that and not ending up with a nursery image.
CHP: Lesley, would like to say something about how your dementia app works?
LP: We launched a partnership with Space Group in Newcastle called IRIDIS. They are one of the leaders in construction technology development. We are aware that there are misconceptions about certain aspects of dementia design, which can come across as patronising. The evolution of dementia research has progressed so far in terms of what colour contrast so that we can now work with muted materials.
The first thing we did was release a homeowner app which is free to download and that takes on board all our essential requirements from our dementia design research. It uses photographs of all the projects we have completed in the last two years in Australia, Japan and the UK to show clients what they can achieve. It’s a reciprocal tool which collects the data from the user so the app uploads photographs along with development tools. In future we will release apps which allow people to test the light and decibel levels of their environments.
We launched the app last year and now have 1,500 users across the world, including places where we have never been such as Chile and Malaysia, which means we can now disseminate the research. Likewise we can now set the next series of questions for the next generation of buildings. The majority of people who have downloaded the app are aged 25 to 45 and are caring for a family member with dementia who is living in a home environment. The majority of these people are assessing buildings that have been constructed in the 90s.
The app is just one of a suite of technologies. The next one we are going to launch is a tool that plugs into a manufacturer’s Building Information Model (BIM) software to detect how dementia friendly a project is so they can detect any design conflicts as they design. This equips people at the time of designing to see where the design could be amended to be more dementia friendly. The operations and maintenance is all recorded in the same model so we can start passive and non-invasive research monitoring over a 10-year period.
AC: When you are looking at commercial aspects, are you looking at durability and infection control?
JD: All our flooring products selected for use in care are fit for purpose. Identifying which ones that were suitable for dementia design was the part that was missing. Now we have an on-line interactive product selector available with over 1,000 products that Lesley’s team have accredited so you can search by pattern, colour, functionality (including bacteriostatic properties, safety and acoustic performance aspects) and dementia design suitability.
SR: It would be great to have some continuity among suppliers so that they can offer tonally complementary products.
JD: Tonal continuity is achieved when floors are no more than 10 LRV steps apart (ideally 8). The LRV ratings of all our products are shown on our website to make selection easy. Plus we’re working with a partner who has developed specific transition strips that can maintain tonal continuity too.
LP: Our challenge is we aren’t just working for the care sector. We had a project recently which was a dementia friendly shopping centre where we were looking at a different set of building regulations.
CHP: Elaine, would you like to say something about what the BSI is doing in terms of developing new guidelines for neuro divergent environments?
Elaine Shine (ES), Standards Consultant, BSI: Two years ago we commissioned a qualitative report around neuro divergent conditions and design for those conditions. We found that our BS8300 series, which focuses on physical impairment, did not go far enough to include people with dementia (and other neuro diverse conditions). The report was based around Euston station and Paddington. It was based on surveys and interviews and physically walking around spaces there to see exactly what the design challenges were. That report developed 11 design themes on which we could base the standard on covering: clarity, layout, flooring, decor, signage, familiarity, acoustics, safety, lighting and other sensory aspects.
The BS8300 series is a very developed standard so we can’t just fit in standards around dementia friendly design. We have to go through the evaluation process so we are working with industry and government to developing a fast tracked standard. This is a sponsored standard for industry that will take about nine to 12 months to develop. After that point we can evaluate it over a period of time and the intention is that it will eventually fit into the BS8300 series.
We have defined the scope and we have included people who experience dementia, autism and potential mental health difficulties. The process also includes a number of steering group meetings to form consensus with manufacturers, associations and academics who have looked into the body of research that is already out there. We began the process in September. We will be making it fully available to some organisations after development so that they can evaluate and use it as much as they can and feedback comments. After two years we will go back and review how it has been used and take on board feedback and revise the standard to fit into the BS8300 series. It could break down into a number of different standards for different conditions. Standards are not regulations.
CHP: What sort of things would like to see in the BSI standard, Amanda?
AC: When we talk about autism, learning disabilities and dementia in the same breath that causes me anxiety because the conditions are extremely different. For me it will be essential that the clients are not looked at in terms of diagnosis and pigeon holed because they are all extremely different.
ES: In our Helen Hamlyn report you can see some of the solutions for dementia and autism can be complementary but some can be contradictory. For example, a public lift can be fitted with a mirror for the benefit of people with physical impairment but people with mental health difficulties are sometimes not comfortable with their physical appearance. It’s about creating standards that drive innovation and are flexible as well. Why we decided to go down the route of a Public Available Specification (PAS) is because it has a two-year lifespan after which point it can be revised and updated. The PAS is sponsored so we can fast track it. Normally a British Standard takes about two years to develop, whereas this can be done within a year.
AC: That could potentially help providers look at an environment that could be beneficial to a client rather than develop something that is going to be unsuccessful.
CHP: What would you like to see in the standard from a design perspective, Sam?
SR: In terms of bedroom layout, it would be useful to have some guidance on where beds should be placed. There’s the problem currently where the CQC might say something different to what other guidelines might say. It doesn’t all quite fit in together so it would be good to have continuity between them. We have not found much information on understanding what the lighting levels for a care home should be. Decoration and patterns would be useful too. We get conflicting information on what patterns are suitable. Some specific care home fabric suppliers have said this pattern is really suitable where they may not be appropriate.
AC: The key thing is the outcome for the person who is living there. Often we get a conflict between the regulators and the individual. There can also be conflict when you talk about the room layout in terms of physical need.
SR: There’s not a catch-all where you can say this is your typical bedroom because there are 10 other things you need to think about in there. Another thing for us is the environment in terms of how it feels. There’s not much information about this. Should it be comfortable or stimulating, restful or homely? All these things mean different things to different people. For us it’s about creating the right environment and not just what specific flooring you need.
CHP: A lot of providing the right environment for those living with is about offering a feeling of independence and freedom.
AC: You can have a negative too where you provide too much space. A lot of research recommends rest stations where people can sit down and have a snack in the case of people who can walk for miles because that’s what they have done all their lives. For some people it can be beneficial to have long, wide corridors but for others it can be confusing. The key thing is if you have designed something and it hasn’t been successful, how easy is it to adapt with a separate seating area, for example?
SR: We have looked at care homes that are in much older buildings and they have the challenges of their smaller corridors or they can be a little bit dark but they do have a homely feel and their rooms have a more domestic feel.
CHP: in terms of lighting, is LED seen as the industry standard now?
LP: There’s a lot research now on the therapeutic benefits of lighting for those people with dementia. We have a higher quality lighting now which can help with dementia and visual recognition. There’s a lot of work being done on circadian rhythm lighting which can help improve sleep patterns and reduce anxiety.
AC: We have been trialling circadian rhythm lighting in our services.
CHP: Where do you see care home dementia design going in terms of innovation?
AC: Technology will be a massive contributor to innovation. We use iPads to assist our colleagues in managing people’s distressed reactions and medication and weight loss, etc. We are also looking at the use of alarm systems and support systems for falls and support and monitoring for people who may like to go out for a walk by themselves. There’s technology around lighting and activities and sensory stimulation. For me it’s about embracing any innovation even if it impacts on the well-being of just one person.
SR: We are moving away from the 1950s lounges and looking at relating environments to where people come from. It’s about creating a nice space that people want to live in and getting away from the nursery and themed spaces. I would like to understand how technology can be brought more into care homes, as well as into people’s own homes, as people will be living at home longer with dementia.
LP: I think we need to stop talking about dementia solely as an issue to consider for care environments. Three quarters of people with dementia are living in the community so the challenge is how we keep people active and preserve their human rights and free access. The future of dementia design is in predictive analytics. Smart technology is making great strides in terms of helping keep people in their own homes. We can have technology such as a smart plug that turns the iron off because the trend over two months is that someone has been leaving the iron on. We need to use technology so that people with dementia can stay working and carry on living in the home environment that they choose to be in. Let’s take the discussion and put it into every environment and accept that it’s not a single condition but it’s a series of different impairments that manifest differently. This is what designers have to understand.
ES: That’s a key point to take away from the standards too. The standard is not just for specialist centres it will include public buildings also. It’s for all design – private and public.
AC: Dementia is not just a disease. It’s how somebody experiences the world. If someone had cancer or a broken leg, they are still treat as an individual and it’s how you adapt the environment to suit their needs and that’s how we should embrace dementia. It depends on what outcomes someone needs and where they can live safely.