“Why don’t we go into the garden?” – why care home gardens for dementia are not used more

As a Garden Designer I was asked to redesign several dementia care gardens on the trott so my colleague and I decided to investigate the question: “Why don’t care homes use their gardens more?” We wanted to make sure that our Clients have a garden that they will cherish and use to the full. We felt it was important to find out why some designed outdoor spaces around care homes, particularly for dementia, were still not being used, and after a lot of money had been spent on them and they had followed current design guidance.

We planned to work with just 6 care homes, balancing this with our existing busy businesses, but little did we know how a meeting with Sylvie Silver, CEO of National Activity Providers Association (NAPA), would change our world. She, and her charity, are a dynamo within the care sector and our request to her to find us some homes to work with lead to my phone going into melt down. Within two weeks we had 50 care homes across the UK wanting to take part. Clearly the care sector was also asking “Why don’t we go into the garden?”.

We scaled up the project working with 17 across England and Wales during the summer of 2013. We asked them to keep detailed diary records of the interactions their residents living with dementia made in the garden and we also made observations of our own during 20 site visits to a representative group of 7 of the care homes.

In total, we collected almost 1500 pieces of information (this had become a huge project) about the ways that care home staff and residents with dementia used their outdoor spaces. We then spent three months analysing and reviewing all the data we had gathered. We not only found the answer, though not the one we expected, we also put together a lot of information about what residents with dementia liked to do in the garden, the plants they like to interact with, a range of garden layouts and features that help or hinder getting outside easily, the techniques staff use to encourage meaningful interactions with the outside and the procedures that different homes have in place to help residents cross the threshold and spend quality time in their garden.

Early in the Research project, it became clear that the culture of the organisation was more important in determining the quality of the interactions with the outside than the design of the garden. We began to realise we may become unemployed garden designers within the care sector if we continued, should we go on? We decided to kee going and we found that it was the people and not the garden itself that influenced how active and meaningful the garden would be for the residents. During our observational visits we spent as much time looking at the internal workings and practices of the home as we did outside.

Something else emerged too. Because we had a large sample of homes in our study, we could see very different approaches to health and safety, activity provision and management culture. When we plotted our findings onto a diagnostic tool we created, called the Map, we started to see an important correlation. The homes that we identified as being further along the journey towards person-centred or relationship-centred care (i.e. demonstrated that they understood and responded to the individual needs and abilities of their residents) had a much more integrated relationship with their outdoor spaces. The gardens were well used and regularly accessed, it was easier for residents to go outside, residents were actively encouraged to go outside spontaneously, carers and members of staff facilitated the visit outdoors well, and the homes were keen to experiment and try new approaches and features in the garden.

Those homes that had a fearful attitude towards Health & Safety tended not to be using their outdoor spaces to the optimal level for their residents. 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.

For nearly all of the project and the analysis phase we had to confront an uncomfortable truth that a garden for dementia could be a success regardless of the input of a Garden Designer. We had chosen to continue to investigate our original question as it felt morally important to still get to the bottom of what was going on, and avoid a potential future scandal brewing in our own sector. Lots of money is being spent on care gardens, was this a potential waste of money?

As we developed the Map tool to help care settings understand the obstacles hindering their use, and how to move forward, we realised that at times the help of an outside specialist like us was still needed. At last we began to fathom where we may fit in, and why some gardens, even when they met the latest guidance didn’t go onto be successful.

We worked out that the support of a garden designer needs to match the home’s current cultural level and abilities. Designing beyond its capabilities leads to a garden that, once the novelty has worn off, will return to the level of use before the change. The belief that having a new garden can make it used more was firmly dismissed. We had uncovered how to ensure investment in care gardens can support becoming more active, alongside a homes cultural move to person-centred, and ensure this is cost effective.

We are now sharing our findings with the care and design sector, using the Map tool through workshops, presentations and consultations. We are also currently writing a book to enable the Map tool to be used without our presence.

If I had been asked to do a huge self fund research project, investigate the culture of care homes, create a diagnostic tool to support their engagement with the outside and then write a book I would have laughed. I am not a strong academic but do have an inquiring mind that never seems to know when to stop in getting to the answers. Along the way I’ve had to take on many new challenges, learnt new skills and found I’ve drawn on so many of my wider skills from all my previous careers and interests. This has been, and continues to be, an extraordinary journey of what is achievable even when we don’t realise what we are capable of.

Our hope from here is to get our book published this autumn and to begin to change the culture in Care, and the approach of how designers work with their care clients, so residents in care can engage meaningfully with the outside as and when they wish to.

Just another small challenge ahead then…..

For more information on our work see www.stepchange-design.co.uk