Feature

posted 14 Jun 2004 in Volume 9 Issue 4

The care-home environment: Special insights

Have you ever wondered exactly why you cannot find your way around that care home or what problems ‘health and safety’ can create in a care environment? Chris Parker of SISA proposes a new framework for examining the physical-care environment.

Most people are able to continue living in their own home as they get older, but a minority eventually need the support provided by a residential or nursing-care home. In the UK, this currently amounts to around one per cent of people aged 65-74, rising to around twenty per cent of people aged over 85.

The move into a care home can be precipitated by an adverse health event, such as a stroke or fall, or result from a more gradual decline in health, such as the increasing memory loss and confusion associated with dementia.

Making a choice of care home: A problem for both carers and cared for

An older person facing the move into a care home may need help in searching out and choosing between the available options, with relatives or other advisers sometimes having to make the choice on their behalf.

Factors that might be taken into account include the travelling distance for visitors, the general atmosphere as experienced on a visit, and the range of facilities and activities provided.

When it comes to looking at the design and layout of the building, different care homes vary widely, and deciding which will best suit the older person can be difficult. One home might have a large sunny lounge but small bedrooms, another might have large bedrooms but no garden – which would the older person be happiest in?

Making a choice of care home: A problem for researchers examining care homes

A related problem to making a choice of care home exists for researchers. We know that the environment we live in is important for our quality of life, but we currently have little knowledge on how this relates to the care-home environment. While personal preference plays an important part for individual residents, we should be able to identify building features that promote the general quality of life of frail older people.

The National Care Standards Commission sets and regulates minimum standards for care buildings, such as room sizes and facilities, but we have little scientific evidence on how care buildings can make a positive contribution to quality of life. Research has been held back by the lack of a suitable way of describing care buildings. Each building has a significant number of features, which range from where it is located, through the overall layout and size of rooms, down to details of fittings such as door handles. Unless these can be encapsulated in a coherent way, the links with quality of life cannot be investigated systematically.

A new framework for examining the physical care environment

A research team based in the Sheffield Institute for Studies on Ageing has recently completed a three-year research project, which devised a new framework for describing care buildings, and went on to uncover links between the physical environment and quality of life.

The tool is called the Sheffield Care Environment Assessment Matrix (SCEAM), and this article describes the SCEAM and the sometimes surprising insights it has given us into the quality of life of older people in care homes.

The assessment tool, SCEAM, aims to aggregate a large number of building features into a meaningful profile for each building. We based it on a framework of ten requirements of frail older people living in care settings, and these are referred to as the ten ‘domains’ of the assessment:

Four domains cover the universal needs of people living in care settings;
Three domains cover the physical needs of frail older people;
Three domains cover the needs of older people with cognitive problems, such as memory loss and confusion.

Each domain is described briefly below with some examples of relevant building features.

The universal needs of people living in care settings

Privacy. People living in communal settings need opportunities for privacy, for example, when talking to their visitors, or receiving help with their personal care. A building with good provision would have a number of small seating areas where private conversations could take place, rather than a single lounge. The layout would separate public areas from resident bedrooms, bathrooms and toilets. Beds, baths or toilets should not be visible to people passing in the corridor if the door is open. Windows should not be overlooked by neighbouring buildings or pedestrian routes. There should be lockable storage space for private possessions;
Personalisation. The care environment is also the resident’s home and the building should provide opportunities for it to be personalised. In bedrooms, this would include space for the resident’s own furniture and somewhere to display pictures and ornaments. The position of emergency call points should allow choice in the way furniture is arranged. Long, straight corridors provide less opportunity than other layouts to personalise the area around each bedroom door. Communal rooms, including lounges and bathrooms should have storage and display space for personal items. Small garden areas or window boxes outside each bedroom would allow residents to choose their own plants;
Choice and control. The building should provide choice over how and where the day is spent. Good provision would include a variety of spaces such as a quiet lounge with no TV, a kitchenette where drinks and snacks can be prepared, and a room where games or other activities can take place. Seating would include a choice of styles of easy chairs, settees, and upright chairs at tables. Bathroom provision should allow each resident the choice of bath or shower, and residents should be able to control the temperature, lighting and ventilation in their own room;
Community. The building should allow residents to be part of the wider community. The location of the home in relationship to public transport and local services is included in this domain, as well as provision for visitors within the building. Features would include suitable spaces for family gatherings and a room where religious observances could take place. The building should reflect the cultural expectations of the resident group, which may differ between older people in different ethnic groups.

The physical needs of frail older people

Safety and health. Care buildings must protect their often frail residents from harm. This includes adequate lighting in all areas, fire protection, non-slip floors, and control of hot-water temperature. Residents with dementia need safeguards against leaving the building, and intruders should not be able to enter. Bathrooms and toilets should be designed for easy rescue of residents who have fallen, for example, by having the door opening outwards. Bedside lights or nightlights minimise falls when residents get up at night;
Support for physical frailty. Older people with reduced mobility, muscle strength, vision or hearing rely on the environment to compensate for these frailties. Wheelchair users should have full access to all indoor and garden spaces, taking into account corridor width, door widths, and ramps in place of steps. For those able to walk, the journey between bedroom and communal rooms should be short, with continuous handrails and seats at intervals. Visual contrasts between fittings, such as handrails and their background, help residents with reduced vision. Door handles, taps and toilet flushes should be easy to grip and turn;
Comfort. The indoor environment should be warm without being over-heated, well ventilated and not tainted with unpleasant smells. Light levels are important, with glare from unshaded windows being equally uncomfortable as inadequate/low lighting. Good sound insulation prevents sounds from different areas combining to give an intrusive and distracting level of noise.

The cognitive needs of frail older people

Support for cognitive frailty. Older people with memory loss or confusion depend on the environment to support their remaining abilities. There are a number of ways the overall design and layout of the building can help them move around and identify where they want to be. Individual bedroom doors are easier to identify if they have a recognisable position in relation to a window, corner or alcove than if they are on a long featureless corridor. In an ideal layout, the direction of the main communal spaces and toilets would be clear from each bedroom door. External views through corridor windows help residents orientate themselves within the building;
Awareness of the outside world. The building can help to keep residents in touch with the time of day, weather and season, and the daily activity going on in and around the building. Features that promote this include windows with low sills, a view of outside activity, such as a busy street, and a view of natural landscape that changes according to the weather and the season. A building with good provision would have adequate natural lighting in all spaces, and the lighting and temperature would vary throughout the building and throughout the day rather than being artificially constant;
Normality and authenticity. Residents with cognitive deficits function better in an environment that feels familiar to them. A building with good provision would have spaces, materials and décor that are domestic rather than institutional. Lounges would have a number of small lamps rather than large strip lights, and dining rooms would be small, seating no more than eight people. Natural materials are preferable to the wipe-clean fabrics often used for practicality. Bathrooms with medical fittings can avoid a clinical appearance by adopting the décor of an ordinary domestic bathroom.

Some examples of building profiles

The SCEAM gives us a framework for describing any residential or nursing-care building in a profile of domain scores. In total, there are over 300 building features across the ten domains, and we score each domain by counting the proportion of relevant features that are present in the building. For example, the domain ‘privacy’ has 40 features, and a building with 30 of these would score 75 per cent.

Table one illustrates the profile of scores by contrasting two different individual care homes:

A residential care home with less than 20 beds, converted from a large house built in the 19th Century;
A modern purpose-built nursing home with over 60 beds, divided into a number of units, some of which specialise in the care of people with dementia.

Table one: Profile of scores for two care homes

Small residential home - percentage scores in following areas:

Universal
Privacy – 66
Personalisation - 43
Choice/control - 60
Community - 55

Physical
Safety/health - 73
Support for physical frailty - 50
Comfort - 75

Cognitive
Support for cognitive frailty - 37
Awareness of outside world - 55
Normality/authenticity – 75

Large nursing home – percentage scores in following areas:

Universal
Privacy - 62
Personalisation - 15
Choice/control - 34
Community - 60

Physical
Safety/health - 88
Support for physical frailty - 66
Comfort - 71

Cognitive
Support for cognitive frailty - 26
Awareness of outside world - 39
Normality/authenticity - 45

What the table tells…

In the first set of domains, universal requirements for people in care settings, the buildings differ little in their scores for privacy and community, both showing around half to two-thirds of the potential features. For personalisation, the large nursing home has only 15 per cent of the relevant features, with the small residential home scoring much higher at 43 per cent, although still showing less than half the features in this domain. Similarly, the small residential home offers almost twice as many features relating to choice and control.

In the domains related to the physical needs of frail older people, comfort scores are approximately equal. Safety/health shows the highest scores of any domain, with the large nursing home having slightly better provision. Support for physical frailty is again higher in the large nursing home, but overall the scores are lower, with up to half the design opportunities being missed.

Finally, the domains relating to the cognitive needs of frail older people show the surprising finding that the nursing home, which was purpose-built for dementia care, achieves lower scores than the residential home. This reflects the nursing home’s long featureless corridors and uniform, often artificial environment, compared with the more domestic and recognisable layout and varying environment of the converted large house.

Is quality of life related to building design?

The development of the SCEAM was the first step in our research. We then wanted to investigate the quality of life of the residents, many of whom were too frail or cognitively impaired to give us their own views. Fortunately, methods already exist for studying quality of life in this group, based on observation by researchers and proxy information from care workers. These methods have been validated by previous research in SISA and elsewhere. We were able to collect a number of relevant measures including the level of activity of residents, their apparent level of well-being, and the degree to which they showed positive emotions, such as pleasure and contentment. In the analysis we took account of the characteristics of residents, which are known to relate to quality of life, such as their level of frailty, and we also accounted for a measure of the ‘care culture’ among the staff, as this differed between buildings.

Positive relationships with the domains

Our findings showed that a number of the SCEAM domains had positive relationships with quality of life. In buildings with good choice and control, residents showed greater well-being. Where provision for community was high, residents were more active.

Where the building design gave good support for cognitive frailty, residents showed more positive emotion.

Where support for physical frailty was high, residents were more able to move around and control their immediate environment.

Some more surprising results

Only one domain showed a negative relationship with quality of life: in buildings with high provision for safety and health, residents engaged in less enjoyable activity, and were less able to move around and control their immediate environment.

Care homes are understandably subject to many health and safety regulations: they must protect their frail residents, as well as function as work places and settings for medical interventions. However, perceived pressures from relatives and fear of litigation may foster a risk-averse environment, which acts against some aspects of quality of life.

A couple of examples of the negative impact of certain safety and health factors are:

The extreme rarity with which we observed residents having access to garden spaces, for fear of the harm that might occur if they wander from the premises or fall;
Safety precautions that can impede the free movement of residents with limited strength and mobility. A common fire-protection device keeps doors closed with such force that they are difficult to open. More innovative solutions to these conflicts between safety and freedom are already available, such as door-closers that allow free swing unless there is a fire, and others are being developed.

Some conclusions

This research project, which was funded by the Engineering and Physical Science Research Council, has developed a new way of assessing care buildings for older people. The profile of scores describes the building from the point of view of the residents, and we found that the scores relate in a measurable way to quality of life. Apart from its potential use in further research, the SCEAM has clear applications within the care sector, where individual care providers can use it to audit their own buildings and identify areas where performance can be improved. In general, we found that provision in existing buildings falls well short of the potential maximum for each domain. Some changes would clearly not be possible without rebuilding or extensive refurbishment, but others are achievable with much more modest outlay.

We now know the kind of questions that need to be asked about a residential or nursing-care building. Does it provide integration with the wider community, choice over where to spend the day, and opportunities for privacy and personalisation? Does it support residents with reduced mobility, strength, vision or hearing? Does it help residents with failing cognition make the best use of their remaining abilities? These questions are all backed up by a detailed specification of the relevant building features.

The research team, which includes colleagues in the University of Sheffield School of Architecture and in the Department of Human Sciences at Loughborough University, is now looking at adapting the assessment tool for the related environment of sheltered housing for older people. We hope that future research and industry guidance will raise the contribution that building design can make to the quality of life of older people living in supportive environments.

Chris Parker trained in psychology, computing and medical statistics. Her specialist areas are older people’s health, well-being and social care with a particular emphasis on ‘Design in Care Environments.’ The Sheffield Institute of Studies on Ageing (SISA) can be contacted via Doug Emery at: d.emery@sheffield.ac.uk or by one on 0114 222 9861.