Designing and managing care homes for people with dementia

March 2002 - Ref 312
Designing and managing care homes for people with dementia

The proportion of residents in care homes who have dementia is rising. Caroline Cantley, Professor of Dementia Care, Northumbria University, and Bob Wilson, consultant in care home design, studied seven recently built specialist homes for people with dementia which have been nominated as examples of good practice. They identified principles for providers involved in setting up or developing high quality care homes for people with dementia. The study found:

• Early stages of planning and setting up a new home or unit are crucial in laying good foundations for future practice. Good planning included:

- ensuring plans matched local needs;
- developing a clear service model according to local circumstances;
- developing the service model and building design in tandem;
- ensuring sites had good access to community facilities and good public transport.

• Investment in good design benefited residents, staff and the business. The homes studied all had a design brief before design commenced; in some instances, this comprised a detailed document and in others a draft, which was finalised with the co-operation of the designer. Attention to detail enhanced the quality of life for people with dementia.
• Good management was crucial. Best management practice included:

- ensuring staff and management had specific knowledge, skills and commitment for dementia care;
- having staffing levels which provided residents with individual attention;
- recognising that dementia care is emotionally demanding for staff, and for managers, and responding to their needs for support;
- involving relatives and residents with dementia in influencing individual care and the management of the home;
- maintaining good links with local health and social care services, community groups and other local resources.

• The researchers conclude that - while the principles of good practice are clear - there is no single 'right' way to design and manage a care home for people with dementia. Decisions about design, the model of service and economic viability need to be considered in tandem.

Background
The proportion of residents in care homes who have dementia is rising. The National Service Framework for Older People recommends that local authorities and independent care providers should work together to develop specialist dementia care places. Provider organisations will therefore increasingly need to consider setting up specialist dementia care homes or units within homes.

This study draws upon the experience of different types of provider organisation with different financial underpinnings. In so doing, it aims to show how much providers can achieve when they are committed to translating the principles of good dementia care into the realities of everyday life in a care home. Taking seven case studies nominated as examples of good practice, the study identified the principles for good practice in planning, design, management, care practice and staffing.

Planning
The study found that the early stages of planning and setting up a new home or unit are crucial in laying good foundations for future practice. Best practice included:

• Ensuring that service values and principles are explicit and implemented.
• Finding out what people with dementia and their relatives wanted in a home.
• Developing good partnership working with relevant local services and community groups.
• Developing a clear service model; the best option varied according to local circumstances. Considerations included, for example: the balance between nursing and social models of care; whether to have a specialist home or integrated dementia unit(s); whether to incorporate respite places or day care places; whether providing a 'home for life' is a goal; and the extent to which the home will have a homogeneous or mixed resident group in terms of dependency and other social characteristics.
• Considering carefully the optimum size for the home and units within the home. There are significant benefits in having small-scale units (defined variously as around 8 to 15 residents). For economic reasons, however, providers often find it necessary to have group sizes of 15, with overall home sizes of over 45. Larger homes and units do not preclude high quality care but the experience of living and working there is inevitably qualitatively different to that in a smaller setting.
• Ensuring that the designer is given a clear brief and either has appropriate experience or is capable of and committed to the relevant research. The homes studied all had a design brief before design commenced; in some instances, this comprised an excellent, detailed document and in others a draft, which was finalised with the co-operation of the designer. Small independent companies or owner/managers may lack resources or necessary experience and have to rely upon experienced designers and building professionals to guide and deliver them. Selecting the right designer is therefore essential.
• Ensuring that fundamental dementia design principles are addressed in creating a homely environment for residents, for example, by observing domestic scale, where appropriate, in design and using familiar materials and colours.
• Ensuring a smooth transition from building contract to operation by treating the opening of a new home as a project in itself.
• Planning in detail for the early days and weeks of the home, considering in particular what residents with dementia, their relatives and the staff group will experience.

Design
Effective design provides the basis for a successful home. In commercial terms, good design:

• improves residents' quality of life;
• results in greater staff efficiency;
• is attractive to purchasers and relatives;
• incorporates cost-effective use of space;
• can improve occupancy rates.

The publication of National Minimum Standards in accordance with the Care Standards Act 2000 sets new requirements for designers and providers. The basic accommodation needs of people with dementia are the same as for other residents. However, people with dementia particularly benefit from an environment that provides:

• small-scale living units;
• familiar features and a homely style;
• scope for involvement in ordinary domestic activities;
• good signage and 'cueing' features, for example, by providing well-lit, inviting entrances to day rooms;
• additional space for daytime activities.

Good design:

• meets the needs of disabled residents;
• maximises independence;
• enhances self-esteem and confidence;
• demonstrates care for staff;
• is orientating and understandable, for example, by the provision of easy visual access to day rooms - for both residents and staff - and by the use of materials and objects of interest as cues for following or 'sensing' a route;
• reinforces personal identity;
• welcomes relatives and the local community, by, for example, the provision of attractive, comfortably furnished entrance foyers, public and semi-public sitting areas;
• allows control of stimuli, such as the provision of a separate quiet room.

Basic site features condition the design of a new home, although the designer often has little or no influence on site selection. Many criteria can be applied in selecting a site. However, in practice, price, availability and access to a strong local community and a frequent bus service are the prime determinants. Looking at the case study homes, the research found:

• Only two homes studied were single-storey. Although access to gardens from two-storey homes was not so easy, residents valued the views.
• Gross floor areas of residents' rooms varied from 13-18m2 but the important feature was the net usable floor area with a rectangular shape of 12m2 (as recommended by the New Minimum Standards).
• Staff differed about the merits of having combined or separate dining- and sitting-rooms. However, the former provided a larger space for activities and enabled more efficient use of staff time.
• Staff were more concerned about having manoeuvring space in en-suite facilities than about the size of residents' rooms, so long as there was adequate space around the bed to attend to residents.
• Only one home had showers in every en-suite facility. The use of these was limited because most residents could not stand, or even sit, in the shower and all needed assistance. In addition, few had experience of using showers. Nevertheless, the majority of staff interviewed considered that showers should be provided in new homes because future generations of residents are more likely to be accustomed to showers and therefore less likely to become discomforted or distressed.
• The value of colour on residents' room doors was uncertain. It appeared more important to have a large frame for a personal photograph or picture.
• Staff favoured having an area where all residents could meet. However, this was an expensive feature unless it could be created by combining spaces such as the entrance foyer and adjoining day rooms.

None of the homes studied used sophisticated technology related directly to residents' care. Some interviewees raised concerns about human rights and ethical issues in relation to new technology. However, if and when such concerns were addressed satisfactorily, it would be possible to install appropriate equipment.

Management
Some specialist dementia care homes are independently owned. Many are part of larger 'parent' provider organisations, which may not understand the differences between dementia care homes and homes for physically frail older people.

One of the most significant tasks for a parent organisation is the appointment of the care home manager. The culture and practices of a home are in large part determined by the care home manager. The case studies indicated that the most effective managers:

• Knew about, generally had direct experience of, and were strongly committed to providing person-centred dementia care.
• Demonstrated commitment to a culture in which staff communication and interaction with residents are valued as core work.
• Maintained good multidisciplinary links with a wide range of health services, social care services and other community groups.
• Were committed to involving relatives and residents with dementia in influencing care practice and the management of the home.
• Were equipped to address the ethical dilemmas that arise in dementia care, for example, in balancing the promotion of autonomy for people with dementia against decisions being made by others in the 'best interests' of people with dementia.
• Had the personal qualities associated with good leadership in dementia care settings, such as a non-hierarchical approach, leading by example and, encouraging and stimulating creativity and innovation.
• Recognised that dementia care is particularly demanding of staff and responded to their needs by, for example: ensuring good communication and a sense of staff involvement and ownership; by handling staff emotions and inter-relationships well; and, by providing support through good staff supervision.

In addition, parent organisations supported managers by ensuring that they:

• were clear about their roles and responsibilities;
• had as much autonomy as possible;
• felt valued and supported; and
• had ongoing management development opportunities.

Care practice
The case study homes all pursued person-centred dementia care. Achieving this requires strong management commitment if staff are to move beyond the tasks and routines of care to develop practice that is imaginative and sensitive to individual residents. The research indicates that a manager can support staff in this approach by ensuring that they:

• Communicate well with residents in every aspect of life in the home.
• Compile and implement care plans that are full, person-centred, and appropriate.
• Facilitate appropriate activities for all residents, including everyday activities such as helping with the washing up or doing some gardening.
• Meet the needs of people with dementia for good nutrition and enjoyable mealtimes.
• Recognise and address the general health, spiritual and sexual needs of people with dementia.
• Provide palliative care when necessary.
• Minimise 'challenging' behaviour by understanding the person with dementia and by adapting the environment or care practice to better meet the individual's needs.
• Strike a good balance between the protection of residents and the quality of life gains that come from taking some risks.
• Maintain residents' links with their local community as far as possible.
• Involve relatives in ways that are appropriate to the needs and circumstances of individual residents and their families.
• Provide support for relatives either individually or through support groups.
• Are aware that people with dementia are vulnerable to abuse and will respond appropriately to any suspected abuse.

Staffing
The study highlighted the following features in the case study homes:

• Staffing levels were appropriate for meeting residents' needs. The most common care staff/resident ratio was approximately 1:4. In homes with poorer staff/resident ratios, care staff felt under more pressure to get on with tasks rather than spend time with residents.
• The contribution of domestic, catering, laundry, maintenance and administrative staff was valued.
• Staff recruitment and selection procedures were effective. The study homes found that applicants' values, attitudes and warmth of feeling were more useful predictors of good care practice than prior experience or qualifications.
• Induction arrangements provided the support that new staff needed and imbued them with the culture of the home.
• Care staff felt valued as individuals, supported and appropriately rewarded; working with people with dementia is very demanding of staff.
• All staff had good foundation training in dementia care as well as access to broader training and development opportunities.
• Staff management (for example shift patterns, cover arrangements) provided residents with consistency of care.
• Any staff working in respite or day care facilities had skills appropriate to that setting.

Conclusion
Our knowledge about how best to design and manage care homes for people with dementia has advanced significantly but there is still much to learn. This study concludes that while the principles of good practice are clear, there is no single 'right' way to design and manage a care home for people with dementia. Decisions about design, the model of service and economic viability need to be considered in tandem. With current standard revenue funding, providers of specialist dementia care homes have to compromise in combining the implementation of best practice principles and achievement of financial viability.

About the project
The research was undertaken by Dementia North, the regional dementia services development centre based at Northumbria University, in collaboration with Chapplow Wilson Associates, an independent consultancy which provides specialised services in designing and building for care.

The project was based on seven case studies of specialist dementia care homes and on a literature review. The case study homes were selected to include a broad range of types of homes and provider organisations. Each home and/or organisation was recommended to the researchers by experts in the field as being an example of good design and as having a reputation for good dementia care. The case studies involved observational visits to each home during which the researchers variously had formal and informal discussions with residents, relatives of residents, care and support staff, home managers, service planners, staff from health and social services agencies, and architects and other building professionals.