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Designing dementia nursing and residential care homes

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DOI: 10.1108/14769011211270765

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Journal of Integrated Care
Emerald Article: Designing dementia nursing and residential care homes
Karim Hadjri, Verity Faith, Maria McManus

Article information:
To cite this document: Karim Hadjri, Verity Faith, Maria McManus, (2012),"Designing dementia nursing and residential care homes",
Journal of Integrated Care, Vol. 20 Iss: 5 pp. 322 - 340
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JICA
20,5 Designing dementia nursing and
residential care homes
Karim Hadjri and Verity Faith
322 School of Planning, Architecture & Civil Engineering,
Queen’s University Belfast, Belfast, UK, and
Maria McManus
Independent Dementia Care Consultant, Belfast, UK

Abstract
Purpose – This study seeks to appraise the design of nursing and residential care homes for people
with dementia in Northern Ireland using the design audit checklist developed by the Dementia
Services Development Centre – DSDC.
Design/methodology/approach – The appraisal used postal questionnaires, based on the DSDC
essential design criteria, that were sent to facility managers. This was conducted in order to establish
the level of compliance with these criteria to achieve a dementia-friendly home, and to ascertain
whether there are any noticeable differences between nursing homes and residential care homes.
Findings – The study identified the types of homes that were seen as failing to meet most of the
DSDC design criteria and, in particular, which criteria are not met according to their managers. Results
from this sample suggest that nursing homes align better with DSDC criteria than residential care
homes. The study concludes that the majority of managers perceive their care homes to meet over
50 percent of the essential criteria, with just over 5 percent below the 50 percent mark.
Research limitations/implications – Given that this study used postal questionnaires more
research is needed in order to validate results. Behavioral and policy implications are crucial aspects
that will be the subject of future research which will involve post-occupancy evaluation.
Practical implications – More attention to dementia-friendly building design needs to be taken into
consideration by residential care homes, and more improvement would still be required by nursing
homes not meeting all criteria.
Originality/value – The paper highlights the importance of dementia-friendly building design and
the requirements for more care in designing and fitting care environments for people with dementia.
Keywords Dementia, Nursing homes, Care homes, Architecture, Health care, Social care,
Northern Ireland, Medical conditions, Social care facilities
Paper type Research paper

Journal of Integrated Care
Vol. 20 No. 5, 2012
pp. 322-340
q Emerald Group Publishing Limited
1476-9018
DOI 10.1108/14769011211270765
Overview
This study seeks to assess the design of dementia nursing and residential care homes
in Northern Ireland using the Dementia Services Development Centre (DSDC) dementia
friendly design essential criteria. It also attempts to establish the level of compliance of
these facilities using self-assessment checklist through questionnaires completed by
53 facility managers during 2011.
Dementia is a progressive disease, meaning that a person’s ability to remember,
communicate and understand the world around them is impaired by developing brain
disease. People with dementia can benefit from skilled care and support in order to
minimize the impact of the condition on the person’s ability to function and remain
independent.
 There are about 750,000 people in the UK living with dementia, whose care costs the Designing
UK economy around £20 billion (Alzheimer’s Society, 2007 as cited in Alzheimer’s residential
Society, 2011). Long-term institutional care and informal/unpaid care make up the
majority of this cost (Luengo-Fernandez et al., 2010). In response to this challenge, the care homes
UK Government designed Living Well with Dementia: A National Dementia Strategy to
improve the lives of people with dementia, their families and their carers (Department of
Health (DH), 2009). Additionally, the UK Government through the Prime Minister’s 323
challenge on Dementia propose to focus on three key areas one of which is “to create
dementia friendly communities that understand how to help” (DH, 2012, p. 5). Similarly,
Mitchell (2012) highlights the growing interest in “dementia friendly communities”
which should provide a supportive and caring environment to the increasing number of
people with dementia.
Given the demographic implications of ageing and the expected increase of the
number of people with dementia, the provision of care environments which meet their
needs becomes critical. In the UK care is provided by local authorities’ social services
and private or voluntary organizations. Many people with dementia need an increased
level of support and care as the condition progresses. As a result of the impairments
caused by dementia, people with dementia need an environment which supports them
to optimize their abilities. Depending on the needs of the person with dementia, some
people require access to nursing home or residential care home[1]. Dementia 2012:
A National Challenge describes how well people are living with dementia in 2012 in
England, Wales and Northern Ireland (Alzheimer’s Society, 2012).

The impact of environment and design

Cognitive impairment affects the individual’s perception of the environment and has an
impact on spatial orientation as identified by Passini et al. (2000). A decline in wayfinding
(how people orient themselves in the physical environment), can have a negative
psychological impact by causing confusion and agitation or aggression in those with
cognitive impairment and is important as it affects the wellbeing of the individual.
Reduced cognitive function is related to wayfinding abilities, thus the physical
environment can impact on dementia residents by affecting their spatial orientation. It is,
however, noted that even those with severe cognitive impairment still show some ability
to navigate successfully within the physical environment (Passini et al., 1998). Wayfinding
outdoors for people with dementia has also been investigated and led to design guidelines
for dementia friendly neighbourhoods in the UK (Mitchell and Burton, 2010).
Additionally, health promotion by design was proposed by Joseph (2006) as a means
to improve sleep, support orientation and wayfinding and reduce aggression and
disruptive behaviour. The provision of quiet environments, the use of distinguishing
colours for labelling rooms and spaces, large signs, and simple building configuration,
can aid with wayfinding (Joseph, 2006). However, sensory and cognitive impairments
are still not well understood or effectively addressed in terms of design, particularly in
relation to extra care housing, also called very sheltered housing or assisted living
apartments (Croucher, 2008). Lighting for people with dementia is also highlighted by
Torrington (2007) as an important design consideration, such as providing a natural
external view and adequate natural lighting for circulation spaces.
The physical environment is associated with wellbeing and is increasingly
important for those with cognitive impairment. Additionally, it has a wide range of
JICA impacts on outcomes for users ( Joseph, 2006), and an effect on wellbeing. This is
20,5 particularly important for those with cognitive decline as the physical environment can
be used to facilitate wayfinding improve their quality of life and increase their
autonomy (Bonnefoy, 2007).
Passini et al. (2000) also argued that there are three design aspects highlighted in the
literature dealing with therapeutic environments; these are: the general character of the
324 setting; the spatial organization of the unit; and the design of specific spaces.
Housing Learning and Improvement Network (LIN)[2] proposed design principles
for extra care housing in relation to cognitive impairment (Nicholson and Heather,
2004). These related, in particular, to facilitating wayfinding and reducing frustration,
namely ensuring sufficient natural lighting, the use of landmark features throughout,
and avoiding the use of complex circulation such as long corridors with changes in
direction.
On the other hand, Hodges et al. (2006) examined reference materials and produced a
matrix of variables looking at how to create an optimum environment for people with
dementia. They observed nine design principles that suggested general environmental
concepts crucial for a dementia day care centre environment. However, these principles
are qualitative and open to interpretation, and would be very difficult to implement
or use as part of a design audit.
Alzheimer’s Australia (2004) position paper on “Dementia care and the built
environment” suggests that care settings for people with dementia should have a domestic
size and character, e.g. small-scale clusters within large care homes and successful floor
plans that facilitate wayfinding. Similarly, it proposes design recommendations for the
en-suite toilet and bathroom and social space; however, it does not propose specific design
guidelines. Additionally, it considers the optimum design of outdoor spaces and staff
working spaces by suggesting a number of design recommendations. Similarly,
Alzheimer’s Disease International (1999) proposed some interesting recommendations for
the design of gardens and courtyards which can be easily implemented, such as use of
seating, pathway design, suitable plants, raised flower beds and circular paths. Likewise,
Mitchell et al. (2003) proposed design principles for outdoor environments that ensure that
the environment is familiar, legible, distinctive, accessible, comfortable and safe. While
Calkins (2009) suggests that private bedrooms and smaller domestic in scale groupings of
residents are features that benefit them.

Strength of the evidence base

There are examples of good practice concerned with the design of dementia friendly
environments; however, design tools and guidelines used in these examples are not
evidence-based and are rather anecdotal (Smith et al., 2004). Fleming et al. (2009)
argued that little is certain when it comes to the design of dementia friendly physical
environments. In addition, Croucher (2008) contends that sensory and cognitive
impairments are neither understood nor addressed in terms of design.
Nonetheless, according to Marshall (2001) there is a “consensus of views” on
designing dementia facilities highlighting that this type of accommodation should,
amongst other things, compensate for disability, maximize independence, be
understandable and easy to orientate around, and control or balance stimuli. Cantley
and Wilson (2002) echoed Marshall’s statement on consensus on design features and
added the commercial benefits of good design, such as greater staff efficiency,
improving occupancy rates and cost-effective use of space (Cantley and Wilson, 2002). Designing
Marshall (2001) argues that there is international consensus about what forms good residential
design for people with dementia given also the paucity of research in this area. She also
adds that there are other issues that pose a challenge to designing for dementia; these are care homes
the cost of building, building regulations and cultural appropriateness.
Marshall (2001) suggests a number of design principles to ensure that the design of
residential facilities for people with dementia should compensate for disability, 325
maximize independence, enhance self-esteem and confidence, demonstrate care for
staff, be orientating and understandable, reinforce personal identity, welcome relatives
and the local community, and allow control of stimuli. She argues that these can be
achieved if the following design features are considered:
. small in size;
.
familiar, domestic, homely in style;
.
plenty of scope for ordinary activities;
.
unobtrusive concern for safety;
.
different rooms for different functions;
.
age-appropriate furniture and fittings;
.
safe outside space;
.
single rooms big enough for lots of personal belongings;
.
good signage and multiple cues where possible, e.g. sight, smell, sound;
.
use of objects rather than colour orientation;
.
enhancement of visual access; and
.
controlled stimuli, especially noise (Marshall, 2001).

Fleming et al. (2009) used Marshall’s (2001) schema to evaluate the available evidence.
They concluded that research supports design aspects such as the use of unobtrusive
safety features, enhancement of visual access and the optimization of level of
stimulation. They also pointed out that there is still insufficient high-quality research
on some design features. Similarly, Fleming and Purandare (2010) conducted a
comprehensive literature review on the design of environments for people with
dementia, using the schema developed by Marshall in 2001, which provided a means of
reviewing the literature against a set of recommendations.
The available literature indicates that there are soft guidelines developed by a few
organizations; however, the extent of evidence-based design that informed these
guidelines is unknown or appears to be weak. More well-designed studies are still
required in order to strengthen the evidence-base and provide the support needed to
improve the design of the physical environment of dementia care facilities.

Tools for appraisal

In terms of design appraisal tools, it appears that there are various methods available to
study dementia care environments as highlighted by Cutler et al. (2006) and Forbes and
Fleming (2012). Cutler et al. (2006) concluded that the Multiphasic Environmental
Assessment Procedure (MEAP) appears to be the most comprehensive instrument and
probably the most established one (Sloane et al., 2002); however, the physical environment
JICA features are represented by only one component. Additionally, Forbes and Fleming (2012)
20,5 assessed the three tools most internationally recognized for nursing home assessments
that include dementia-specific units; these are the MEAP (Moos and Lemke, 1984), the
Therapeutic Environmental Screening Scale (TESS þ ) (Sloane and Mathew, 1990;
Sloane et al., 2002) and the Professional Environmental Assessment Protocol (PEAP)
(Lawton et al., 2000). They concluded that the PEAP is a complex tool requiring an
326 experienced researcher and a considerable amount of time to complete.
PEAP was used by Schwarz et al. (2004), who conducted an environmental
assessment to evaluate a facility before and after environmental modifications, and to
record various aspects of the environment that support environmental experience
attributes (awareness and orientation; safety and security; privacy; regulation and
quality of simulation; functional abilities; opportunities for personal control; continuity
of self; facilitation of social contact). They concluded that the PEAP produced evidence
of the space usage changes that were motivated by the new residential setting. They
also used behavioural mapping and focus group interviews to strengthen the study.
Forbes and Fleming (2012) selected the Therapeutic Environment Screening Survey
for Nursing Homes (TESS-NH) survey, despite its limitations, and the Environmental
Audit Tool (EAT) which was developed to adapt hospital wards for long-term use by
people with dementia (Fleming et al., 2003) in New South Wales, Australia. They
concluded that “the final analysis the EAT audit tool, as adjusted, provides an acceptable
alternative to the TESS-NH that is quick and easy to use, valid and reliable and arguably a
better measuring instrument. It also reflects the current environmental requirements
described in the international literature for dementia residences”. EAT bears many
similarities, in terms of design principles and domestic philosophy, with the DSDC Design
Audit and uses “Yes” or “No” answers in addition to some with a “Not applicable” option.

Implications for our study

Our work supports the view that the recommendations suggested by Marshall (2001)
and DSDC appear to be a reliable framework by which to assess dementia facilities. The
Design for Dementia Audit Tool developed by the DSDC at the University of Stirling
(Cunningham et al., 2008) is based on the work of Marshall cited above. This tool
provides a valuable basis for use as a briefing guide for designers of new facilities. The
aim of this tool is “to ensure that the built environment does not present insurmountable
barriers to those who use it” (DSDC, 2007, p. 2). It would aid organizations to develop an
action plan following self-assessment. It is required that 100 percent of “essential”
criteria of the Design for Dementia Audit Tool are met in order for a facility to gain Gold
Standard accreditation by DSDC. Both the “recommended” and “essential” criteria
contribute to an overall rating for each building in terms of its suitability for people with
dementia. DSDC guidelines are now acknowledged by the UK National Health Service
and regularly used for the design of new dementia care facilities or adaptation of existing
ones. Additionally, DSDC centres in the UK (University of Stirling, Belfast and London)
are actively promoting their Dementia Design Audit Tool through effective
dissemination and training events, and have contributed to this research.

Methods
Our study seeks to establish the level of compliance of nursing and residential care homes
in Northern Ireland using the DSDC design audit. This research used self-assessment
checklist through postal questionnaires completed by facility managers, in order to Designing
identify which types of homes appear to meet most of the DSDC design criteria (above residential
75 percent) and, in particular, which criteria are met.
The study was based in Northern Ireland, given the ease of access to information care homes
and budget limitations that have also restricted the study to postal questionnaires
which are an inexpensive method to gather data from a large and dispersed population.
The study collected data using categorical variables with Yes/No/Not Applicable 327
responses, and given that the questions were based on the DSDC audit tool, the criteria
have equal value and no weighting involved. The study acknowledges that there are
obviously limitations with this type of data collection, such as the potential of missing
important design problems and the lack of quantitative data.
Privacy of the respondent was protected at all times. There was no information on
the questionnaire that could identify the respondents. A letter accompanying the
questionnaire explained the purpose of the study and asserted that the questionnaire
was anonymous.
The research methodology is divided into four stages:
(1) Sampling strategy. Compiling a complete list of nursing and care homes with
dementia patients in Northern Ireland using the information available from the
DH, Social Services and Public Safety of Northern Ireland.
(2) Questionnaire design using the DSDC audit tool.
(3) Carrying out the questionnaire. Postal questionnaires were sent to managers of
all nursing and care homes with dementia patients in Northern Ireland.
(4) Questionnaire analysis and interpretation of results.

Stage 1: sampling strategy

There are currently 75 nursing homes and 44 residential care homes operational in
Northern Ireland; that is a total of 119 homes registered with the DH, Social Services
and Public Safety certified to provide care for people with dementia. These facilities are
designed to offer nursing and care to a variety of older people. The maximum number
of service users from all categories, including dementia, that can be accommodated in
these 119 homes is approximately 15,392. These provide care to nearly 2,500 people
with dementia (DHSSPSNI, 2010).
The study used non-probability sampling given that there was no control on who
will return the completed questionnaires. No attempt was made to control bias, and
therefore there are limitations to the reliability and trustworthiness of the feedback of
respondents (subjectivity issues).

Stage 2: questionnaire design

The questionnaire design consisted of 76 questions structured into 13 sections as in Table I.
These included 69 questions related to the “essential” criteria of the DSDC first edition of
the audit tool (2008). The second edition of the tool was not available at the time of research.
Completion was by a “Yes”, “No”, N/A answer followed by a Comment box.
There were two questions asking for specific information such as current number of
dementia patients and maximum capacity. There was also an open-ended type question:
Does the design of the physical environment matter and make a difference to people
who suffer from dementia and to their carers?
JICA
Section Questions on
20,5
1 Location, type of building, care capacity, and whether or not the home has a garden
2 The entrance hall and wayfinding
3 Lounge and day room design
4 Meaningful occupation and activity
328 5 Bedroom design
6 Private/en-suite toilet area
7 Communal toilet area
8 Private/en-suite bathroom/shower
9 Communal bathroom/shower
10 Dining room
11 Treatment/examination/consulting room
Table I. 12 Exterior
Questionnaire sections 13 General principles

The questionnaire was piloted with the manager of a dementia care unit which had
been recently built and had benefited from the DSDC expert advice during the design
stage. The final questionnaire was improved following the responses and comments
from this manager.

Stage 3: carrying out the questionnaire

The study relied on a postal questionnaire sent to the managers of 119 residential care
and nursing homes across Northern Ireland. Prior to posting the questionnaires,
managers were contacted by telephone and informed about the aim of the research, the
importance of the questionnaire and their valuable contribution.
In total, 53 questionnaires were completed and returned after six weeks; hence a
44.54 percent response rate.

Stage 4: questionnaire analysis and interpretation of results

The questionnaires were analysed by calculating the tally and percentage for each
“Yes/No” question for nursing homes and residential care homes to allow for
comparative analysis based on the level of compliance with the DSDC essential criteria.
This allowed the identification of design criteria that were not met as well as the
amount of homes that appeared not to meet most of the DSDC design criteria (below
75 percent).

Results
Results of the questionnaire analysis are summarized in this section. The level of
compliance with DSDC guidelines for the whole sample is examined, and more
emphasis is given to the dementia friendly design differences between nursing homes
and residential care homes.
The study was conducted in Northern Ireland due to budget limitations and the
need to future access to the facilities to conduct post-occupancy evaluations. The
sample of respondents is well spread across the country with about 23 (42.6 percent)
homes located within the Belfast metropolitan urban area. The 2008 population
estimate for Belfast metropolitan urban area is 575,231 inhabitants, while the total
population of Northern Ireland is 1,775,003.
 Reponses to questions related to the 69 DSDC essential criteria show that not all Designing
criteria are met, and that only five essential design criteria are fully met by all homes. residential
These are those concerned with bedroom design, toilet roll position and ease of reach,
carpet design in lounge/day room, and adequate space for staff to assist residents. care homes
Those not meeting the criteria in more than 20 percent of homes are: the dining room
size (not domestic in scale), the position and fixing of mirrors in the private and communal
bathrooms, the lack of prompts to suggest the function of the bathroom, the design of 329
enclosure fence for exterior spaces, access to toilets from communal area not very clear,
discreet storage space not available, contrasting colour for toilet seats not used, and
domestic-looking wall-tiling or water-proofing material not present in bathrooms.
All respondents agreed that the design of the physical environment matters and
makes a difference to people with dementia and to their paid carers. Some argue that
there is need for a lot of natural lighting. Others suggest that the “environment should
be calm, homely, comfortable, warm and clean”. A respondent acknowledged the
importance of the physical environment but also highlighted the need for adequate
care: “Although the environment is not the answer, it can make providing good care for
people with dementia much more accessible”. Another manager highlighted the
importance of the physical environment in relation to quality of life: “In terms of
dementia, it is essential to provide an environment conducive to serenity and calmness
while continuing to support stimulation”. Orientation and avoiding confusion are key
elements of the design, as suggested by two managers who state the following: “Yes it
is important as it aids memory and avoids further confusion”, and “Yes it is very
important for perception, orientation and comfort” (Table II).

Nursing homes compared to residential care homes

Comparing the same criteria across the two types of homes it can be said that 47 out of
69 are met more positively by nursing homes than residential care homes. That is,
only 22 criteria of 69 are met better by residential care homes. Nursing homes thus
comply better than residential care homes with DSDC guidelines (68 vs 32 percent)
(Table III; Figure 1).
The study attempted to identify which types of homes were seen as failing to meet
most of the DSDC design criteria and, in particular, which criteria are not met. Nearly
87 percent of criteria are met by 75 percent or more of nursing homes, while about
80 percent are achieved by 75 percent or more of residential care homes (Table IV).
Design criteria that were met by less than 75 percent of homes for both types of
accommodation are:
. Mirrors are well situated and are designed to be removable or easily covered.
.
The dining room is small and domestic in scale, e.g. no more than ten people at a
time.
.
In the examination/consulting/treatment room, there is a table to ensure the
person can access food and drink when/if appropriate.
.
Enclosure (wall or fence) that is conspicuous and screened by planting.

Criteria that need further consideration within residential care homes are concerned with
signage, colour scheme in toilets, extra space for transfer from wheelchair or hoist,
prompts to help identify the function of a room, location of mirrors in bathrooms,
 20,5

330
JICA

of results
Table II.
Design audit tool
questions and summary
Yes N/A Total valid Percentage
Space Essential criteria questions responses responses responses meeting criteria

Garden 1. Does the facility have a garden or outdoor spaces? 52 0 53 98.15

Hall/entrance/way-finding 2. There is particularly clear signage to help way- 47 1 52 88.68
finding for everybody., e.g. pictorial representation;
large clear lettering
3. There is good access for those with physical or 52 0 53 98.15
mobility problems including wheelchair users
4. Is there contrast between signs and background 48 1 52 92.45
mounts?
5. Is the base of the signs around 4 feet or 1.2 metres 42 3 50 84.31
from the ground?
Lounge/day room 6. The carpet/floor covering is blended into the overall 48 6 47 100
colour scheme yet contrast with walls and furniture
7. Toilet facilities are near at hand and either visible 45 0 53 85.19
from a seated position or well sign-posted from
communal areas
Meaningful occupation and activity 8. There is easy access to safe outside space with 48 3 50 96
facilities for residents to engage in light gardening or
exploring, where desired
Bedrooms 9. If an individual’s room, the entrance is personalised, 51 0 53 96.3
easily visible, identifiable and secure
10. If no en-suite, toilet facilities are nearby and have 51 2 51 100
clear signage and visibility
Toilet area (en-suite) 11. The door contrasts well with the bedroom walls 42 7 46 89.36
12. The room is attractive and pleasant 49 4 49 100
13. Any ceramic wall tiling or waterproof lining 43 4 49 88
materials are domestic in appearance, avoiding
strong pattern or sterile white colour
14. Tiling and wall colours contrast clearly with 43 4 49 88
sanitary fittings and grab rails
(continued)
 Yes N/A Total valid Percentage
Space Essential criteria questions responses responses responses meeting criteria

15. If toilet areas lack natural light, colours are light and 46 4 49 94
reflective such as warm whites to maximise light
levels
16. The colour of the toilet seat contrasts with both the 41 2 51 78.85
toilet bowl and the floor
17. Toilet roll is within easy reach of toilet 48 5 48 100
18. Mirrors are well situated and are designed to be 39 2 52 75
removable or easily covered
19. There is discreet storage space available for bulk 44 2 51 84.62
items such as incontinence pads
Toilet area (communal/wheelchair 20. The door contrasts well with adjacent walls 49 0 53 92.59
accessible)
21. The room is attractive and pleasant 52 0 53 98.15
22. Any ceramic wall-tiling or water-proof lining 41 0 53 77.78
materials are domestic in appearance, avoiding
strong pattern or sterile white colour
23. Tiling and wall colours contrast clearly with 43 1 52 83.02
sanitary fittings and grab rails
24. Skirting contrasts with floor finish where possible 49 1 52 94.34
25. If the toilet lacks natural light, colours are light and 49 1 52 94.34
reflective such as warm whites to maximise light
levels
26. The colour of the toilet seat contrasts with the toilet 41 0 53 77.78
bowl and the floor
27. Toilet roll is within easy reach of toilet 52 0 53 98.15
28. Mirrors are well situated and are designed to be 38 0 53 70.37
removable or easily covered
29. There is discreet storage space available for bulk 42 0 53 77.78
items such as incontinence pads
(continued)
residential
Designing

care homes

331

Table II.
 20,5

332
JICA

Table II.
Yes N/A Total valid Percentage
Space Essential criteria questions responses responses responses meeting criteria

30. In shared areas (lounges and dining rooms), access 40 0 53 75.93

to toilets or very clear signage is conspicuous from
as many viewpoints as possible., e.g. contrast
signage
31. There is adequate space for transfer from 45 1 52 86.79
wheelchair or hoist, especially when two carers are
required
Bathroom/shower room (en-suite) 32. The door contrasts well with adjacent walls and has 44 7 46 93.62
a sign
33. The room is made recognisable through the 43 7 46 93.48
visibility of shower or bath fittings
34. The function of the room is prompted through the 34 6 47 72.34
display of items such as toothpaste, toothbrushes,
shampoo, etc.
35. The room is pleasant to be in and makes people feel 45 6 47 95.74
relaxed and comfortable
36. Any ceramic wall-tiling or water-proof lining 38 6 47 80.85
materials are domestic in appearance, avoiding
strong pattern or sterile white colour
37. Tiling and wall colours contrast clearly with 41 6 47 87.23
sanitary fittings and grab rails
38. Skirting contrasts with floor finish where possible 43 6 47 91.49
39. Mirrors are well situated and are designed to be 34 6 47 72.34
removable or easily covered
40. There is discreet storage space available for bulk 41 6 47 87.23
items such as incontinence pads
Bathroom/shower room (communal/ 41. The door contrasts well with adjacent walls and has 47 2 51 92.31
wheelchair accessible) a sign
42. The room is made recognisable through the 47 2 51 92.31
visibility of shower or bath fittings
(continued)
 Yes N/A Total valid Percentage
Space Essential criteria questions responses responses responses meeting criteria

43. The room is domestic in appearance, without a 40 2 51 78.85

hospital type assisted bath or shower
44. The room is pleasant to be in and makes people feel 48 2 51 94.23
relaxed and comfortable
45. Any ceramic wall-tiling or water-proof lining 41 2 51 80.77
materials are domestic in appearance, avoiding
strong pattern or sterile white colour
46. Tiling and wall colours contrast clearly with 41 2 51 80.77
sanitary fittings and grab rails
47. Skirting contrasts with floor finish where possible 47 2 51 92.31
48. Mirrors are well situated and are designed to be 36 2 51 69.23
removable or easily covered
49. If there I a hoist or shower chair this is non- 43 3 50 86.27
threatening in appearance with safety notices
discreetly positioned
50. There is adequate space for a minimum of staff to 51 2 51 100
assist
51. There is privacy screening to keep bath/shower out 46 2 51 90.38
of sight of others passing
52. There is adequate space for wheelchair use 50 2 51 98.08
53. There is discreet space available for bulk items such 40 7 46 85.11
as incontinence pads
Dining room 54. The dining room is small and domestic in scale., 30 1 52 56.6
e.g. no more than ten people at a time
Examination/consulting/treatment 55. There is a table to ensure the person can access food 37 9 44 82.22
rooms and drink when/if appropriate
Exterior 56. A safe secure, enclosed environment 43 1 52 81.13
57. Enclosure (wall or fence) that is conspicuous and 37 5 48 75.51
screened by planting
58. Easy access from the building to a safe outdoor area 46 2 52 90.38
59. A patio that is level, non-slip and hard surfaced 44 4 50 90
(continued)
residential
Designing

care homes

333

Table II.
 20,5

334
JICA

Table II.
Yes N/A Total valid Percentage
Space Essential criteria questions responses responses responses meeting criteria

60. Is the patio well maintained and clean, especially in 43 3 51 86.27

over-shadowed areas?
61. Service covers (e.g. manhole covers) that are 43 1 53 83.02
generally concealed
62. No steep slopes or other barriers within the outdoor 45 1 53 86.79
area
63. The way back to the building is easily visible to 43 2 52 84.62
those using the outdoor area
64. The plants are not harmful 42 1 52 81.13
65. The planting and grassy areas are well maintained 50 1 52 96.23
General principles 66. Colours are pastel and muted with no abrupt 52 0 53 96.3
changes in colour of floor patterns in areas that
people with dementia use
67. The colour scheme makes good use of contrasting 51 0 53 94.44
colours to aid visibility. For example, skirting
boards are in colours that contrast with wall and
floor finishes
68. The floor coverings have consistent colours and 51 0 53 94.44
textures to minimise confusion
69. Wallpaper/carpet patterns that are jazzy or contain 49 2 51 94.23
images of real life objects have been avoided
availability of discreet storage spaces, small domestic-scale dining room, extra space in Designing
staff room, enclosure within garden and open space that is conspicuous and screened by residential
planting, and adequate outdoor signage. While criteria that need further consideration
within nursing homes are: location of mirrors in bathrooms, function of bathroom evident care homes
to user, wall-tiling/lining that is domestic in appearance, dining room that is domestic in
scale, extra space in staff room to allow a visitor to access food and drink, and enclosure
within garden and open space that is conspicuous and screened by planting (Table V). 335
Conclusion
With an increasing number of older people in the UK living with dementia there is urgent
need to provide a supportive and caring environment for these people to live independently

Criteria met
Percentages of homes meeting criteria Nursing homes % Residential care %

100 2 2.90 5 7.25

90-99 26 37.68 17 24.64
80-89 23 33.33 20 28.99
70-79 11 15.94 14 20.29
60-69 6 8.70 13 18.84 Table III.
50-59 1 1.45 0 0.00 Percentages of homes
.50 0 0.00 0 0.00 meeting criteria by type
Total number of criteria 69 100.00 69 100.00 of home

Figure 1.
Percentages of homes
meeting criteria by type of
home

Criteria
Nursing homes Residential care
Homes meeting criteria Number % Number % Table IV.
Percentages below and
,75% 9 13.04 14 20.29 above 75 percent of
Equal to or above 75% 60 86.96 55 79.71 homes meeting criteria by
69 100.00 69 100.00 type of home
JICA
Nursing Nursing Residential Residential
20,5 homes homes care homes care homes
Question (n ¼ 33) (%) (n ¼ 20) (%)

Question 9. Is the base of the signs around 4 feet or 1.2 29 87.88 13 65.00
metres from the ground?
336 Question 20. The colour of the toilet seat contrasts with 28 84.85 13 65.00
both the toilet bowl and the floor
Question 22. Mirrors are well situated and are designed 23 69.70 16 80.00
to be removable or easily covered
Question 32. Mirrors are well situated and are designed 22 66.67 16 80.00
to be removable or easily covered
Question 34. In shared areas (lounges and dining 27 81.82 13 65.00
rooms), access to toilets or very clear signage is
conspicuous from as many viewpoints as possible.,
e.g. contrast signage
Question 35. There is adequate space for transfer from 32 96.97 13 65.00
wheelchair or hoist, especially when two carers are
required
Question 38. The function of the room is prompted 21 63.64 13 65.00
through the display of items such as toothpaste,
toothbrushes, shampoo, etc.
Question 40. Any ceramic wall-tiling or water-proof 23 69.70 15 75.00
lining materials are domestic in appearance, avoiding
strong pattern or sterile white colour
Question 43. Mirrors are well situated and are designed 21 63.64 13 65.00
to be removable or easily covered
Question 44. There is discreet storage space available 27 81.82 14 70.00
for bulk items such as incontinence pads
Question 52. Mirrors are well situated and are designed 23 69.70 13 65.00
to be removable or easily covered
Question 57. There is discreet space available for bulk 28 84.85 12 60.00
items such as incontinence pads
Question 58. The dining room is small and domestic in 18 54.55 12 60.00
scale., e.g. no more than ten people at a time
Question 59. In staff room, there is a table to ensure the 24 72.73 13 65.00
person can access food and drink when/if appropriate
Question 60. A safe secure, enclosed environment., 29 87.88 14 70.00
e.g. are outside areas enclosed by a secure unclimbable
fence or wall, with concealed or disguised gates
Table V. Question 61. Enclosure (wall or fence) that is 24 72.73 13 65.00
Design criteria that were conspicuous and screened by planting
met by less than 75 Question 67. The way back to the building is easily 30 90.91 13 65.00
percent of homes for both visible to those using the outdoor area., e.g. use of
types of accommodation marker plants, artefacts or colours

and with dignity. The physical environment is becoming increasingly important for those
with cognitive impairment and particularly people with dementia, given that it can
improve their quality of life and increase autonomy and wayfinding abilities.
According to several authors, there is a “consensus of views” on the design of
dementia facilities and on their additional features such as compensating for disability,
maximizing independence, being understandable and easy to orientate around,
and able to control and balance stimuli. Other authors point out that there is still Designing
insufficient high-quality research on some design features. residential
DSDC audit tool is seen as a reliable tool to appraise dementia friendly
environments. This tool was used by this study in order to identify the level of care homes
compliance with DSDC design guidelines of nursing homes and residential care homes
registered in Northern Ireland.
The questionnaire analysis indicates that the main deficits in the design features in 337
care environments are:
.
provision of easily accessible, safe and enclosed outside space;
.
signage;
.
design of en-suite toilets and bathrooms;
.
provision of mirrors which can be removed or covered up; and
.
provision of discreet storage space.

In terms of the differences between nursing homes and residential care homes, it
appears that nursing homes align better with DSDC criteria than residential care
homes (68 vs 32 percent). Over 80 percent of criteria are met by 75 percent or more of
nursing homes and residential care homes.
The findings of this research provide useful dementia friendly design guidance to
architects, interior designers, occupational therapists and facility managers of
dementia nursing homes and residential care homes. More attention to these design
aspects should be given to residential care homes, while nursing homes environments
should aim to meet all DSDC criteria. Patients, their relatives and carers will benefit
from more dementia friendly environments as suggested by this study.
Finally, the paper highlights the need for more evidence-based research to inform
the design of dementia care facilities. Behavioural and policy implications are crucial
aspects that will be the subject of future research which will involve post-occupancy
evaluation.

Notes
1. In the UK a variety of terms are used to refer to specialised housing with or without care.
For the purpose of this study nursing homes and residential care homes were examined.
The term “nursing home” continues to be used in Northern Ireland, while in the rest of
the UK this is now called “care homes with nursing”. Similarly “residential care homes”,
which are homes where nursing is not provided, are nowadays called “care homes”.
Nursing homes are designed for people who are physically or mentally frail or for those
who need regular medical care. These homes have an on-duty, 24 h a day qualified nurse
to provide nursing help but also provide personal care for patients such as assistance
with washing, getting dressed and giving medication. Some homes are registered to offer
a specific care need such as dementia or terminal illness (Elderly Accommodation
Counsel, 2011).
2. The LIN, formerly responsible for managing the DH’s extra care housing capital
programme, is the leading “knowledge hub” for a growing network of housing, health
and social care professionals in England involved in planning, commissioning, designing,
funding, building and managing housing with care for older people (www.housinglin.
org.uk/).
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340
About the authors
Dr Karim Hadjri is a Reader in Architecture at the School of Planning, Architecture and Civil
Engineering at Queens University Belfast (QUB). Karim is an architect with a Master of
Philosophy (1989) and a Doctor of Philosophy (1992) in housing studies completed at the Joint
Centre for Urban Design, Oxford Brookes University. He has worked as a scholar in the United
Kingdom, UAE and Saudi Arabia, and managed academic units and research centres in both
Cyprus and Colombia. His teaching and research interests include architectural design, housing,
computer-aided-design, and post-occupancy evaluations. Karim is particularly interested in
inclusive design and how the physical environment can be improved to fit the needs and
requirements of the older user in particular. His more recent research explores the influence of the
physical environment on various user groups including people with cognitive impairment.
Karim Hadjri is the corresponding author and can be contacted at: k.hadjri@qub.ac.uk
Verity Faith is from Northern Ireland, she studied at Queen’s University, Belfast where she
completed a BSc in architecture in 2007. She worked in a local architecture firm on various
projects and international competitions; including healthcare, leisure and education buildings. In
2010 she completed the postgraduate degree in architecture, with a thesis focusing on healthcare.
Following this, she commenced a PhD within architecture. Her research interests include design
for dementia and improving wayfinding.
Maria McManus is a registered Occupational Therapist. She has worked in public services as
a clinician and manager in acute hospitals general adult mental health services and psychiatry
of old age. Formerly, she was Director of the Northern Ireland office of the Dementia Services
Development Centre of the University of Stirling. Maria has extensive consultancy experience on
design of the built environment for people with dementia and contributed to the development
of the Design for Dementia Audit Tool. She is co-author of Hearing, Sound and the Acoustic
Environment for People with Dementia (2010), DSDC, University of Stirling.

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