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Getting to the root of the matter
Why aren’t care homes using their outside spaces?

Debbie Carroll and Mark Rendell explore why care homes are not using their outside space and how this can be improved.

While working with care providers to develop their outdoor spaces, we noticed that the designed outside spaces in some care settings were not being used as much as we thought they should be. This concerned us as it threw into doubt the success of the designs that had been implemented and, potentially, the reputations of garden designers, too.

If, as a result of design efforts, there was no increase in residents using their gardens than before the designer came along, was the design support cost-effective? And if not, what were the implications of this for our own practices, and for our peers’ too?

This led us to a deceptively simple question that needed an answer, ‘Why aren’t care home gardens used more actively?’

Although it sounds simple, the research journey we went on to find the answer challenged our assumptions about the role of a designer in care homes (and other similar settings).

We assumed the answer would lie in the outside space somewhere. It didn’t. In fact, we found it in an altogether more complex and unfamiliar place: the indoors, or more accurately, in the subtle and subconscious practices and procedures, norms and daily habits, beliefs and values, of the care setting itself. In other words, in the setting’s ‘care culture’.

Care culture is on a spectrum

To delve into this more, we visited care homes and plotted all the different interactions and relationships that they had along a spectrum, from task-oriented care near the bottom towards increasingly person-centred and relationship-centred care at the top.

From this, we could clearly see the factors that influenced care homes’ engagement levels and attitudes towards the outdoors.

Our key findings identified that the more mature and advanced the care home’s culture, the higher their levels of active and meaningful engagement with the outside space, regardless of the garden’s condition or appearance.

Those homes that were practising person-centred care and beyond tended to use their staff to engage residents with the garden and were correspondingly more spontaneous, prepared and informal in the way their residents interacted with their garden.

Care home cultures that were lower on the spectrum, tended to use garden features and elements to help activate the outside space and were more group-based, formal and timetabled in their interactions with the outside space.
We also discovered that fearful attitudes towards health and safety effectively ‘capped’ the active use of the outside space, particularly for those homes on the lower areas of the spectrum.

A tool to help articulate care culture and match design support

Following this discovery, we felt it was important to compile the information and help describe the different indicators of care culture along the spectrum, as clearly and simply as possible.

To do so, we created a ‘map’ to help care settings identify and locate their current care culture practices and then plan a route forward along the spectrum towards greater relationship-centred care practices and, increasingly, active use of the garden.
We didn’t want to just say ‘what’ needed to be done to activate care home gardens, but show ‘how’ it could be done as well.

It was during the creation of the map that we identified how a designer or outside specialist could support care settings more successfully and cost-effectively. We described a range of ways to support care settings at different points along the spectrum, including, but not restricted to, purely design-based interventions.

We helped care homes to establish where their culture was before work started and resources were committed; this enabled the designer to then match and deliver what would be sustained by the home as it progressed on its culture change journey, towards greater relationship-centred care and more active engagement with outside spaces.

Additionally, the map also located ‘person-centred care’ a little above halfway along the spectrum of care culture practices we identified. This enabled care settings to locate where they were against person-centred targets and identify a route forward, based on the ‘steps’ included on the map, to reach and exceed person-centred care practices.

A new approach to collaborating with care settings

Following the research and development of the map, we could see why previously designed gardens had fallen out of use after the novelty had worn off. In the main, it was because they had been ‘over-designed’. They were beyond the current capacity of the setting to use them optimally.

To address this, we developed a new approach to collaborative working between designers or outside specialists and care settings, we call it ‘relationship-centred design’. It requires the care setting to be in the driving seat and ensures that the designer’s support starts from the setting’s current culture, not from where either party thinks it should be.

This is a major shift in garden design and landscape architecture practice from one-off, whole site design interventions to a more sensitive, relationship-based approach. This new approach entails smaller (and perhaps more modest) interventions, but on a longer-term basis, alongside the care home’s culture change journey. It is based on being fully aware of the care culture, prevailing attitudes and beliefs of the setting.

What does this mean for care settings?

For a care home manager who wants to use their outside space more actively, a key priority must be to take a deeper look at the subtle and often subconscious processes, habits and beliefs that make up their setting’s care culture.

Not only could these be holding the care team back from engaging their residents more actively with their outside spaces, but it is through an honest review of care culture practices that they can also gauge how person-centred they are and what they may need to address to move forward on their own culture change journey to more advanced care practices.

Addressing care culture and embarking on a culture change journey is not a ‘quick-fix’. It requires dedication, courage and determination on the part of everyone, but the rewards are manifold, for both staff and residents.

For care settings on the lower half of the relationship-centred care spectrum, it’s important to avoid the trap of believing that a new garden will transform the home’s culture overnight by resulting in more active engagement with the outdoors.

Our findings strongly indicate that if the care setting hasn’t been using what it already has outdoors, then it’s unlikely that the new garden will overcome these well-established and ingrained normative practices once the novelty value of the new space has worn off.

The issue is not with the garden itself, but the fact that the care home believes that a new garden will kickstart excitement and engagement with it. These care homes need to look at their current attitudes and practices to using the outside space before the design process starts. The garden can then be appropriately improved to facilitate more active use of it.

The outside space is part of the overall care environment

We have heard a lot of reasons why care setting gardens are not being used more actively, including not having enough money, time or staff.

However, we noticed that many of the homes performing at the top of the spectrum in our research appeared to have the fewest resources and still managed to create seamless and spontaneous engagement for the residents between the indoors and outdoors. They had worked out that they couldn’t afford not to do it.

It did not require more money, time or staff for these homes to open the doors and help residents to cross the threshold into their garden, it was simply seen ‘as just another room’, and a valued part of the overall care environment.

What was actually involved here was culture change: focusing increasingly on the needs of their residents as individuals, and replacing fear from lack of knowledge, with confidence that they knew what their residents wanted to do and were determined to fulfil those wishes, in a safe, imaginative way.

There are many reasons to commit to culture change and to become more person-centred in care practices, not least because the Care Quality Commission demands it. The dividend of practising at this higher level appears to us to result in happier residents, who are more fulfilled and contented in their lives, naturally engaging with the outdoors, as and when they wish to.

We now draw on all our skills to support our care and design sector clients to grasp the nettle that is care culture, working proactively to help them identify their subtle and complex care cultures and to support their efforts to progress along the care culture spectrum, reap the rewards of greater engagement with the outdoors for their residents and collaborate with outside specialists more cost-effectively too.

Debbie Carroll and Mark Rendell are Directors of Step Change Design.
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