In 2003 the Department of Health commissioned The King's Fund to develop specific programmes to enhance the environment of care as part of the department’s work to improve patient experience. The most recent of these was a programme to improve the care environment for people with dementia in hospital to support the implementation of the national dementia strategy and the Prime Minister’s ‘Challenge on Dementia’.
Following the completion of the EHE programme, the work on dementia-friendly design is being taken forward by the Association for Dementia Studies (ADS), University of Worcester.
What are the current issues for people with dementia?
Each year the number of people living with dementia is growing and this number is expected to double during the next 30 years. It is estimated that 40 per cent of people aged over 65 in general hospitals will be living with dementia and most of the people living in care homes will likely have dementia or cognitive problems.
In particular, hospital stays are recognised to have detrimental effects on people with dementia who have longer lengths of stay and poorer outcomes. However, there remains a low level of knowledge in the health professions – even among those who have been trained to care for people with dementia – and among estates and facilities staff about what makes a positive therapeutic environment for people with dementia. The volume of applications for the EHE programmes and training events has shown that there is a considerable level of interest in creating dementia friendly environments and there is a desire across the service for practical advice to enhance the quality of the care provided to people with dementia.
What has the EHE programme achieved?
The EHE programme to improve the environment of care for people with dementia was funded by the Department of Health. It involved 23 teams from acute, community and mental health NHS trusts who worked on a range of projects across the dementia care pathway and sought to make hospital environments less alienating for people with cognitive problems. In 2009, ten mental health trusts joined the dementia care programme, and ten acute trusts and two community trusts followed in 2010.
Projects have demonstrated that relatively inexpensive interventions, such as changes to lighting, floor coverings and improved way-finding, can have a significant impact. Evaluation has shown that environmental improvements can have a positive effect on reducing falls, violent and aggressive behaviours, and improving staff recruitment and retention. The EHE schemes have shown that it is possible to improve the quality and outcomes of care for people with dementia as well as improve staff morale and reduce overall costs by making inexpensive changes to the environment of care.
Tools and resources: Developing supportive design for people with dementia
To support clinical and care staff, managers and estates colleagues, The King's Fund has produced a range of resources to enable hospitals, care homes, primary care premises and specialist housing providers to become more dementia friendly.
Download the assessment tools
Download the tools from the Association for Dementia Studies
Guide to carrying out the assessment
The EHE assessment tools contain seven overarching criteria and a set of questions to prompt discussions between clinical/care staff, managers, estates and maintenance colleagues, people with dementia, their families and carers.
It is recommended that the environmental assessment should be carried out jointly by a lay person, ideally a carer of a person with dementia, together with clinical/care and estates/maintenance staff. Involving a range of people in the assessment is recommended because the process of undertaking the assessment will enable discussions that are likely to encourage improvements in both the physical environment and the quality of care delivery.
The time required to undertake the assessment will vary according to the size of the area(s) being assessed but should take no longer than an hour to complete. A section has been provided for comments to identify areas of good practice and issues of concern.
Design principles
Supporting the assessment tools, the design principles have been developed using the experience gained from the EHE programme to build on the evidence and international best practice in creating more supportive care environments for people with cognitive problems and dementia.
The design principles are presented as a wheel with five sections grouped around the desired outcomes of: easing decision-making; reducing agitation and distress; encouraging independence and social interaction; promoting safety; and enabling activities of daily living. Listed under each of the section headings are a series of elements that are known to support, encourage and enable people with dementia in unfamiliar buildings.
It is unlikely that every element can be introduced at once unless a new build or comprehensive refurbishment is planned. However, many of the principles are simple and can be introduced with very little financial outlay.
The design principles have been incorporated into each of the EHE assessment tools above.
How were the tools developed?
The tools have been informed by research evidence, best practice and more than 300 survey responses from the United Kingdom and abroad from people who have used the tools in practice. Each of the sections draws on this evidence to develop a rationale for effecting change in care environments. These rationales also address the visuospatial problems often associated with dementia.
The first assessment tool for ward environments was developed in collaboration with NHS trusts participating in The King’s Fund’s EHE programme. Since then more than 70 care organisations have been involved in field-testing the tools.
Tools were subsequently developed for general hospital environments and care homes. Following requests from the sectors, tools have now been developed for health centres including GP premises and for ‘housing with care’ to include extra care housing, retirement communities and sheltered housing.
How the tools are being used
Evaluations of the tools indicate that they are being used to:
Assess progress in developing more dementia-friendly environments
Secure finance to improve the physical environment of care
Influence managers and estates/maintenance colleagues to support change
Educate staff and help change attitudes
Improve signage, flooring, lighting and colour schemes as part of maintenance programmes
Make small-scale improvements eg, purchasing coloured crockery.
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