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8. What do high performing homes do differently?

Updated: Apr 27, 2022

Intro to the series

Step Change Design focuses on encouraging care settings to take a fresh look at their care culture and care practices in order to engage actively and meaningfully with their outside spaces with their residents. In this monthly series we explore ways to make the most of the outside spaces around your care setting to help your residents benefit from stepping outside and enjoying meaningful activities there, as and when they choose.

What do high performing homes do differently?

During our research project we carried out 20 observational visits across seven contrasting care settings, all with a high proportion of residents living with dementia. As garden designers, we quickly realised that engagement with the garden didn’t lie in the design of the space but in the actions and attitudes of the people in the care setting. In other words in the care culture in operation at the setting. We quickly realised that we had to put aside our design-led focus and become instead neutral observers, open to everything that took place, both indoors and outdoors. We felt like innocents abroad, unfamiliar as we were then with care home environments, and found ourselves asking numerous questions about what we were observing that probably seemed obvious to those working in the care setting!

As we stepped out of the familiarity of our designer-world, we decided to follow the evidence wherever it led, seeking out the deeper reasons for why engagement outside did or didn’t take place. We captured what was said, how it was said, what was or wasn’t done, the beliefs and attitudes that influenced why and when residents went outside (or did not), and all the subtle factors that got in the way of simply stepping outside with residents.

The happy accident of our study was the very diverse range of homes we recruited, and the varied ways they delivered their care. This helped us see that the care homes in our study could be placed along a spectrum of care: from the homes that displayed lots of taboos around health and safety issues that made them fearful about going outside through to the homes that we came to describe as operating in a ‘safely imaginative’ way, risk assessing their residents’ abilities to engage with the garden safely and encouraging active engagement with the outdoors, as and when a resident chose to do so.

The diversity in care home practices we observed during our site visits manifested itself in many differences in beliefs about similar things.

For example, in a home with a large pond, with a minimal fence around it, we saw that it was being actively and safely engaged with while at another home in our study it was felt that any water in the garden was just too dangerous for their residents and was simply not allowed.

Some homes told us it was unsafe to eat any vegetables they grew in the garden while another had a huge vegetable growing area which supplied the home and public café they ran with produce they proudly promoted as home grown.

In our last blog exploring ‘Open door policies’ we described a home where the front garden space was used regularly, by residents, including those living with dementia. A group of them liked to sit by the main entrance, watching people come and go, and could see across the car park out the open gateway to the nearby housing estate. It took us several visits to understand what was happening here and that this home was actually practising a high level of what we called ‘Relationship-centred care’.

What set them apart from other homes was how much they knew about their residents so that they knew who was safe to sit outside unsupported and with minimal supervision. They had carried out risk assessments that were focused on what the resident could do safely rather than the risk posed by the setting and its seeming openness, so for those they knew who desired to sit at the front and for whom it was safe to do so, the home enabled this enjoyable and meaningful activity to take place.

For those whom the home felt to be at greater risk, this much loved activity took place after lunch with a cuppa, so was subtly supervised as an integral part of the mealtime activity.

One key aspect that set this home apart from others was that they constantly remained curious to learn more about their residents and then applied all they knew to supporting them to live the lives they wanted to have. They also, importantly, constantly shared what they learnt with colleagues too. This went on every day, far beyond any initial life story capture on arriving in the home, and involved the whole home becoming involved in their care. Whether a member of the team was a carer, in a formal sense, the maintenance officer or chef, everyone encircled the resident in what appeared to be a ‘ring of care’ with the resident at the very heart of every activity, decision and task.

Interestingly when we share this aspect at our workshops and presentations, we are often told that this needs ‘more time’ and ‘more people’. In our study, one of our most relationship-centred homes demonstrated that this was not necessarily the case. It was a home with the barest of resources and so even we were surprised to see during one of our visits that they continued to actively engaging their residents with the outdoors, if they wished to go out, when they had a serious staffing problem to address. The ’ring of care’ simply tightened slightly for the period of the reduced staffing issue but nothing altered in the service they provided their residents. They continued just as they had before the staffing problem.

We witnessed all staff, including the receptionist and maintenance officer, picking up on residents’ desires to go outside and acting on them. We watched staff hand over the care of residents at doorways to each other in a subtle choreography that looked just like passing a relay baton to ensure residents could come back inside while not interrupting the garden visit for others needing their support to stay outside.

We asked how they managed to do all this, when we’d seen other homes with more resources struggle. They stated, almost with disbelief at us enquiring about what felt obvious to them that ‘they couldn’t afford not to make these visits happen’. For many of these residents they knew that if they didn’t go out, or do those things they enjoyed, they were simply harder to care for and created the need for additional support. Simply put, by working together across the whole care setting, completely focused on their resident living the life they choose, the care they provided resulted in happier and more contented residents, who in turn were easier to care for.

We developed a saying during our research, ‘Are the residents passengers or participants?’ Is the care home like a cruise ship where things are mainly done for the residents, a place where meals and clothing magically appear, where there is little engagement in the working of the home and residents seem to be like passengers on a cruise ship, or are they actively engaged in the daily chores and routines of their home, contributing meaningfully and happily to the effective working of the home and how any day may unfold? This was the blurring of the divide between carer and the cared for that we witnessed in these high performing homes, with a home full of laughter and spontaneous happenings resulting from this resident-centred focus and the natural and meaningful activity that follows.

Be inspired by Step Change Design’s new infographic that shares key statistics from their study to help you step outside with residents more.

Connect with Step Change Design on Twitter Debbie Carroll @stepchgdesign

More Blogs in this series Garden Series


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