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News archive - May 2016

Making dementia gardens more accessible

Making dementia gardens more accessible

Debbie Carroll and Mark Rendell from Step Change Design have carried out a large-scale research project to find the answer to the deceptively-simple question - Why aren’t care home gardens used more actively?

Carroll said: “As garden designers, it goes without saying that we want to make sure our clients have a garden they will cherish and use to the full.

“Therefore, we felt it was important to find out why some outside spaces around care homes were still not being used, even after a lot of money had been spent on them and they had followed current design guidance.”

The designers, who have more than 20 years of design experience between them, self funded and carried out an extensive research project with the care sector over the summer of 2013.

After initial interest from 50 residential care homes across the UK and Ireland, the designers selected 24 to join the research study. Seventeen of those remained to the end and kept a month’s worth of detailed diary records of the interactions their residents living with dementia made in the outside spaces, or with the outside space from within the care setting.

The designers also made observations of their own during a number of site visits to a small selection of these homes. They then spent three months analysing and reviewing all the data.

Culture counts

Very early in the process, it became clear that the culture of the care setting - the habitual way of doing things including the attitudes, processes and beliefs - was more important in determining the quality of the interactions with the outside than the quality and design of the garden itself. In particular, the research identified a range of approaches and attitudes towards health and safety, activity provision, condition of the outside space, and management culture among the homes in the study.

Rendell explained: “Those homes that had a fearful attitude towards health and safety tended not to be using their outside spaces to the optimal level. It was more difficult to spontaneously access the outdoors, staff lacked confidence in the outdoor environment, and the homes were generally unprepared for interactions with the outdoor space.

“Many of the most-actively-used gardens were actually quite bland on first sight, but they were very flexible spaces and aided spontaneous engagement for their residents and were basically domestic in scale and feel.”

They then plotted these different approaches along a ‘care culture spectrum’ between basically ‘task-oriented care’ and what they describe as ‘relationship-centred care’ approaches and quickly identified a key finding.

Carroll said: “We noticed a correlation between those homes that were more advanced in their care practices and higher engagement levels with their gardens, regardless of how pretty they were, or the condition they were in. Those homes practising relationship-centred care already understood the importance of engaging with the outside space for those residents they knew liked to be outside.”

Rendell added: “We found it was the person that facilitated the garden visit, and not the garden itself that influenced how active and meaningful the garden would be for the residents. It was to do with the culture of the care setting and how much they knew their residents and then encouraged both their staff and residents to go outdoors that mattered, more than how pretty the garden was.”

A waste of money?

For a long time during the research project, the designers were faced with the very-real possibility that they would be concluding that the services of a garden designer are not needed to increase engagement levels with the outside spaces around care settings.

Rendell said: “The reason why Debbie and I carried out this research was because we feared our services could be a waste of money if residents are still not going outside, even when the home has spent a considerable amount of money on creating a new garden. We had found an important factor in engaging with the outside space that had nothing to do with our services.”

An appropriate role for a garden designer, or any outside specialist, only really emerged at the end of the analysis. The designers went back to their care culture spectrum and realised their support similarly needs to match the care culture of their client.

The danger of a garden design being considered a waste of money was activated when the designer over-designed the space for the actual cultural habits and current relationship with the outside space of the care setting.

Carroll explained: “The key is to find out how the care setting uses the outside space they already have. A new garden for a care setting that does not have embedded habits of engaging with the outdoors is not likely to be regularly used after the novelty value has worn off – the cultural habits and norms that have kept the care setting indoors-focused, despite the new pretty space outside, appear to be too strong to overcome.

“For homes that are lower down the care culture spectrum we identified that our design support needs to be more modest and simply about encouraging more-regular access to the outside space, tackling physical obstacles and layout issues and dealing with any safety concerns.

“A full-blown garden redesign is not necessary or appropriate for these homes. A more-modest budget that deals with access issues, signage, repairs, and safety features, and simply drawing the outdoors into more conversations, or altering seating arrangements to gain a better view, is a much-better investment as it more closely matches the current culture of the home and the immediate next steps on their journey to greater involvement with the outdoors.”

Relationship-centred design

The designers call this new approach ’Relationship-Centred Design’. It demands a rethink in the way the garden designer traditionally understands their role and their approach to creating or developing outside spaces for clients in institutional settings such as care homes.

They want to encourage a move away from one-off, entire-space commissions to more-modest interventions, working closely alongside their client on an ongoing basis, understanding their current care culture, and facilitating the next step in helping them engage more fully with their outside spaces with their residents.

The Care Culture Map Tool and Handbook aim to help both the care sector client and designer, or any outside specialist, to understand where the care home’s cultural practices currently are along the care culture spectrum that is described on the Map and to then match the services of the specialist to this currently-identified position.

Carroll said: ”We want to help the care setting spend its money more cost effectively on the garden that it needs, and to help the garden designer to facilitate and support the development of a successful garden that will result in an actively-used outside space and a better quality of life for those residents who love to go outside.”



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