Areas covered by the audit tool 1: Entrance, corridors, wayfinding and lift

Spaces with activities are powerfully meaningful to people with dementia but can be easily misinterpreted. Successful spaces are those that carry unambiguous meaning, are appropriate for their function and are recognisable at a multisensory level. Well-designed entrances and wayfinding techniques can allow a person with dementia to operate at their best possible level, whilst enhancing their overall wellbeing.

2: Lounge area
A key feature of the group living situation in which people with dementia can find themselves, is the lounge or day room area. This is essentially a social space and should be welcoming, recognisable and normal in appearance. What are sometimes perceived as the symptoms of dementia, can be the person with dementias response to what is going on in the environment .e.g. people can be very bewildered by a lounge which looks like a waiting room. Such effects can be minimised or even reversed if the social and physical environments are person-centred. The room should therefore be age-appropriate and offer a calming ambience that neither over nor under-stimulates the person with dementia. Such an environment offers the potential to enhance a persons self-esteem and confidence and to make relatives and the local community feel welcome.

3: Dining room
People with dementia can easily become malnourished and dehydrated and lose interest in food. A good dining environment can promote peoples interest in their meals whilst facilitating a pleasant dining experience. In addition to paying attention to nutritional needs, care settings should also facilitate the social aspects of eating, with an emphasis on normal, enjoyable and quiet dining and the occasional large celebratory events. As elsewhere, the principle of choosing objects that contrast with the background they are seen against applies here, for example by choosing crockery that contrasts with the table or table cloth on which it is placed and indeed allows the food to be clearly visible on the plate.

4: Meaningful occupation and activity

Inactivity is well recognised as having adverse effects on the physical and mental wellbeing of residents of care homes and hospitals. Frequent and easy engagement in meaningful and/or familiar activities will enhance the wellbeing of people with dementia. It is important to provide facilities that enable all residents to engage in occupation and stimulation that is relevant to the individuals past and current wishes and preferences. Variety is important and should include everyday activities.

5: Examination room
The treatment room can be extremely confusing for a person with dementia and the range of unusual items that it contains can provoke anxiety. It is critical that this environment is designed and managed to encourage the person to remain relaxed, as well as enabling interaction between staff and the person being examined.

6: Hairdressing room
This is an important room because it is associated with going somewhere for a pleasant activity which is very familiar and enhances self esteem. It can also be a highly sociable activity. The room should be very familiar, i.e. clearly recognisable as a hairdressing salon, and not at all clinical or alarming. Waiting comfortably in a queue can be part of the enjoyable experience.

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7: Bedrooms
Residents bedrooms or bed areas are private spaces that should reflect the persons particular culture, preferences and needs. At best, an individual will perceive their bedroom as their own personal home. Unlike other parts of the care home, which are shared, there is an opportunity for the person to retain some power and control over this space. Home is the embodiment of identity, the loss of which can result in the person becoming depersonalised and losing their history and identity. If a person is surrounded by their own possessions, such as family photographs, pictures of themselves, mementoes and books, it is not possible to be wholly reduced to anonymity.

8: En suite provision
Dignity and privacy are of importance in all aspects of caring for people with dementia, but perhaps particularly so in areas of intimate care and need. Incomprehensible fittings and fixtures within a toilet area can disable and demoralise someone with dementia. Attention to simple design features can alleviate this risk. With en-suite facilities, there is an opportunity to personalise the space specifically for the individual resident both according to their care needs and their personal preferences.

9: Communal toilets/bathrooms
In communal areas, the challenge of ensuring dignity and privacy is greater. Furthermore, while bath and toilet fittings may be considered accessible according to the disability specific building standards, it is possible to be regulationcompliant but not dementia-friendly. This risks rendering a toilet or bathroom inaccessible to those with dementia. Again, attention to simple design features can satisfactorily address these issues.

10: External areas

Barrier-free access to the outdoors is essential for maintaining the wellbeing of people with dementia. Gardens, terraces, balconies and roof gardens can provide exposure to natural light and be places for familiar activities such as gardening, hanging out washing, or simply strolling. They can also offer a place to retreat to and experience peace and quiet. The space must be safe for the person with dementia, without feeling like a prison. The principles of appropriately contrasting colours apply to outdoor spaces as well as interiors.

11: General principles

The standards contained in this unit apply across the caring environment as a whole, and contribute to its overall effectiveness and quality.

Development of the tool

This is the second version of the audit tool. It will continue to be reviewed regularly and new versions will be published as more evidence about best practice becomes available.

An evidence-based approach
This pack includes a literature review describing the evidence, which underpins the recommendations of the design audit tool. The review, which was carried out in Australia in 2007 involved grading research papers relating to design and dementia, then evaluating these against a number of design features put forward by Professor Mary Marshall in an earlier literature review carried out in 2001. This literature review is currently being updated.

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How to use the audit tool

All audits should always be carried out by two people, whether they are undertaken by internal auditors or Dementia Centre auditors. Ideally internal auditors should not have been too involved with the building in order to avoid bias. The audit process involves moving through a range of spaces that are used by people with dementia. In some settings, such as care homes, there will be more than one example of particular rooms, such as bathrooms and toilets. In such cases, the auditors will need to assess both individual examples, while gathering enough information to make a judgement about their standard as a whole. The accompanying workbook includes duplicate sections for assessing bedrooms (part 7), en suite provision (part 8) and communal toilets/bathrooms (part 9), reflecting the fact that there will normally be several of these, and they will often differ in layout and design. The overall scoring of the building should reflect the range of standards across different spaces. As an example, poor design in the majority of toilet areas would detract from any single example of a well designed toilet. While the auditor is not expected to examine every space in the building (e.g. all 50 toilets), a sufficient number must be evaluated to provide an accurate overall impression. The workbook includes prompts and suggestions about what to look for in different areas. Where appropriate, additional information may be sought from staff and residents during a site visit. The tool is broken down into units covering different areas. Some environments will not contain all the rooms that are described in the audit workbook (for example, there is unlikely to be a bathroom in a medical centre). Although not all units need to be completed, all areas of a building that people with dementia have access to should be audited. Important: If some units or standards are not relevant to the building you are auditing (for example there is unlikely to be a dining room in an acute hospital ward) they should be ignored and not scored. Each unit is made up of a number of standards. Scoring for each standard is as follows: y standard met (yes): 1 point y standard not met (no): 0 points When carrying out the audit, place a tick in the appropriate box to indicate whether a standard has been met or not met. Space is provided for comment beside each standard and at the end of each section. Each standard falls into one of two categories, as follows:

Abbreviation E

Category Essential

Description The design features in this category are essential criteria, based on research and expert opinion. 100% of the criteria in this category must be met to achieve certification. The design features in this category are recommended in environments used by people with dementia, based on current evidence and international best practice.

Recommended

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Formal certification of a building

The Dementia Centre seeks to promote excellence in the design of environments for people with dementia. Through its design certification service, it aims to recognise best practice and share this knowledge with others. This service is available exclusively from the Dementia Centre, and consists of the following elements: a site visit from two Dementia Centre registered dementia design auditors, one will be an architect a report based on the site visit, derived from an audit carried out using the audit tool a certificate confirming which standard the building has met (see table below) guidance which identifies areas requiring modification prior to certification, should a rating not be achieved on audit y inclusion of the building on the Dementia Centre website as an example of good design to be shared with organisations/individuals who wish to visit well designed sites (optional) y y y y This service is offered both for new builds and adaptations of existing buildings. Please contact the Dementia Centres consultancy service for further information.

The three levels of certification:

y gold (90% or above): an excellent example of design for people with dementia y silver (7589%): a good example of design for people with dementia y bronze (6074%): an adequate example of design for people with dementia

Planning your audit

Bear in mind that managers and staff working in the unit will probably accompany the auditors and will want to engage in discussion about issues raised by the audit process. 1. Before the visit: y look at the plans if available y identify key issues, e.g. the size of the unit, location of toilets, access to outside areas y clarify what is being audited. Is it one room, one flat, one unit/ward, a day facility, a health facility, a cluster of units or wards, or a whole building? Ensure you are confident about likely areas for discussion. Key issues will include: y the number of people with dementia living together (you will need to emphasise that too many people and too much noise are disabling) y being able to see the toilet, toilet door or clear signage for the toilet from communal areas (people will say this is not domestic, but they need to understand what it might be like to need to go to the toilet and not to know how to find it) y the importance of personalised doors to bedrooms (staff may say that the people they care for are too disabled to find their own rooms. It is easy to blame dementia, and they need to show you what they have tried) y easy orientation to all areas that the person with dementia may need to find e.g. being able to locate the lounge and dining room because it can be seen from a number of locations 2. Take: y plans of the area you are auditing y an audit tool for each auditor, plus a spare copy in case an accompanying manager/staff member wants one y digital camera (permission must be sought first, but photographs can form a valuable part of the audit report). Ensure that no residents are photographed

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3. Before beginning the audit, clarify: y the history of the building. Are there any particular issues or problems? y have any renovations been made to the building? If so when and what was the purpose of the renovations? y who is it for? - anyone with dementia - those with alcohol-related brain damage (ARBD) - people with dementia and behaviour which challenges - people with dementia and other conditions (impaired vision, learning disability etc.) - people with dementia who are approaching death - a mixed group of people with and without dementia y the number of people in the facility y their average age y their mobility levels y other information about the people who (will) live there, including their: y background (urban/rural/class/shared trade etc.) y ethnicity y faith y gender 4. Plan a route. Explain that you will need to stop and seek clarification as you go, and that one of the auditors may take photographs. Emphasise that these will not be shared with anyone else without their consent, but solely used as a reminder of key features and to illustrate the report. Even if an internal auditor is not planning a report, photographs are an invaluable aide memoire of key features. 5. At the end of the visit the manager/other staff may want some feedback. They will have received quite a lot from the discussions as you walk around. 6. It is very difficult but absolutely essential to distinguish between issues such as the organisations enthusiasm or quality of care, and specific design features.

The layout of the following pages uses the same format as the audit tool, with the addition of points of guidance for most items. To view the full range of Dementia Centre publications that can assist with carrying out a design audit, visit www.dementiacentre.com.au/shop

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Corridors / Wayfinding

1: Entrance, corridors, wayfinding and lift

Yes
1.1

No Notes
R The entrance to the unit is clean People with dementia are at risk of diminishing self-esteem. A dirty entrance area will swiftly raise anxiety and lower confidence

Entrance area

1.2

The entrance to the unit is welcoming The entrance should look as domestic as possible and should not be intimidating

1.3

The entrance to the unit is tidy People with dementia are at risk of diminishing self esteem. A messy entrance area will swiftly raise anxiety and lower confidence

1.4

The entrance to the unit is well lit If you are under the age of 30, the entrance area is conspicuously bright. If you are aged between 30 and 48, it is very bright. If you are aged over 48, it is bright. There are no dark patches or stripes

1.5

There is good access for those with physical or mobility problems including wheelchair users. Observe: Handrails; lift; ramp; height and accessibility of door handles; disabled parking spaces near building Although this is not dementia specific, it is important that entry is not stressful for the person or their carer since people with dementia will often be very stressed about entering an unfamiliar space

1.6

There is seating to provide opportunities for rest Seating should be domestic in style, comfortable and robust

1.7

The door entry system is discreet. Observe: Alerting staff but not ringing out to disturb residents/ patients/people with dementia The door to whole building and or the door to the living units within it, may have bells and these should not be so loud that they disturb those inside

Corridors
1.8

The colour of the carpet/floor covering contrasts with the colour of the furniture Contrast makes the furniture more visible which is essential for safety

1.9

The colour of the carpet/floor covering contrasts with the colour of the walls This enables people to see where the floor ends and the wall begins. See specialist vision loss organisation guidance

1.10

The skirting contrasts with both the floor and walls This enables people to see where the floor ends and the wall begins. See specialist vision loss organisation guidance

1.11

The flooring is consistent in colour/tone throughout including threshold strips People with dementia often have visuospatial problems and cannot see 3D. It is important that they do not see steps in flat floors, hesitate and potentially tumble

1.12

Large-patterned carpets have been avoided Patterns that look like real objects (fruit, plants etc), swirls and stripes can all be misinterpreted by people with dementia

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1: Entrance, corridors, wayfinding and lift

Yes
1.13

No Notes
R Strong wallpaper patterns have been avoided Patterns that look like real objects (fruit, plants etc), swirls and stripes can all be misinterpreted by people with dementia. Too much visual stimulation may make people restless

1.14

The space has good levels of natural lighting When the artificial lights are turned off during the day, most people can see reasonably well if within three metres of a wall containing a window

1.15

Glare from natural lighting can be managed Curtains and/or blinds are required if there is a danger of glare in bright sunlight

1.16

The space has good levels of artificial lighting If you are under the age of 30, the corridors are conspicuously bright. If you are aged between 30 and 48, the corridors are very bright. If you are aged over 48, the corridors are bright

1.17

The lighting can be controlled according to the time of day There is more than one light switch and more than one lighting circuit

1.18

Ceilings, floors, floor coverings, window curtains and soft furnishings are sufficiently sound absorbent to support communication Ceilings, floors, floor coverings, window curtains and soft furnishings are sufficiently sound absorbent to support communication

1.19

All corridors lead to meaningful places. Observe: Dead ends have been avoided or made interesting Corridors that lead to locked doors or are dead ends will cause frustration and potential anger. Corridors work best if they lead to a sitting area or to some other distraction e.g. access to a garden area that is safe and connected with the main part of the unit

1.20

Corridors are wheelchair accessible Corridors need to be wide enough for a wheelchair to get past someone with a Zimmer frame or walking sticks

1.21

Corridors are of varying widths This is to avoid the tunnel effect. Corridors should be broken up into smaller areas

1.22

Corridors have interesting items on the walls in order to provide focal points of interest e.g. photographs of the locality, something to touch or stroke

1.23

There is seating at frequent intervals to provide opportunities for rest Seating should be domestic in style, comfortable and robust

1.24

There are comfortable handrails to give both physical assistance and a sense of direction/distance Handrails need to be highly visible (contrasting colour to the wall behind), easy to grip, with some tactile indication where sections end for people with impaired vision

1.25

Corridors are well lit If you are under the age of 30, the corridors are conspicuously bright. If you are aged between 30 and 48, the corridors are very bright. If you are aged over 48, the corridors are bright

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