Dementia Gateway: The environment

Case study: Using balconies and roof gardens to access the outdoors

How a balcony in one care home opened up a world beyond the four walls.

Most care home residents rarely get the chance to go outside – and yet it is crucial for mental and physical health.

Read the full case study:

• Understanding the situation - 1. Research and development findingsOpen

  We know that, unfortunately, most care home residents rarely get the chance to go outside and experience other environments (see for example MWC and SCR 2009). And yet going outside is crucial for mental and physical health. The inside air can be stale and overheated, and people need sunlight to manufacture vitamin D, which helps regenerate bones. Bright light helps to set the body clock and encourages better sleep at night. Going outside is something to do, to get away from (perhaps noisy) fellow residents, to see nature and to relate to the world outside.

  There is currently no research on balconies, roof terraces and roof gardens for people with dementia. There is research on the benefits of free access to outside for people with dementia in terms of reducing frustration and resulting behaviour problems (see Zeisel and Silverstein et al 2003).

  Often the cost of land makes it unaffordable for care homes to be low-rise (one floor only). And yet when it comes to thinking of alternatives for outdoor space in taller buildings – such as a balcony or roof garden – often planners and builders have been anxious about the potential risks and avoided them.

  The use of outside space above ground level is still a relatively new phenomenon. The DSDC at Stirling University has published a book (Marshall 2010) which is based on a review of published material and results from a consultation with, and contributions from, a wide range of experts and care providers. The book will need revising as more expertise becomes available. The Health and Safety Executive's Guidance on care homes emphasises health and safety assessments for staff as well as residents, but in addition, visiting small children should be considered (2001 and 2007).

• Understanding the situation - 2. Views collected from key peopleOpen

  The Dementia Services Development Centre at Stirling University received many requests for advice about balconies and roof terraces, and so went looking for examples of where these had been used. One such place was a Belong care home in Wigan. Here, the care team wanted to provide the best possible normal environment, including vital access to the outdoors, and to balance freedom with safety.

• ActionsOpen

  Following discussions between the care team and the architect in the planning stages, the architect included a balcony in the home's designs. Now that the facility is up and running, the balcony offers residents access to pleasant, safe outside space. The balustrade is not intimidating, nor does it make people feel imprisoned. It is also safe because the balustrade is the required 1.1 metres high and it has a flower box on top.

• ResultsOpen

  According to the manager, this attractive balcony is now well used by the residents as a place to meet and talk, as well as a place for activities. She said that all of her residents, including many with dementia, really appreciate it: 'On sunny days people sit and chat and have lunch together. On poor days our residents go out with their coats on and watch the world go by. The balconies have been a great addition, a real get together place. We have planted areas and hanging baskets.'

  On reflection the Belong balcony features some positive and some less positive aspects. On the one hand the wooden balustrade is very attractive and hard to climb over, because it has flower boxes on the top. But having these boxes means, however, that you cannot lean on the balcony while watching the world go by. In the areas where there is no planter box, it looks very attractive and normal, but some may think that it looks easier to climb over at these points.

  If there are some residents who present dangers because of their behaviour (say, for example, they throw things over the balcony), they should not be in this area without a member of staff being in attendance also, any more than any other part of the residence. The background work and consultation behind the recent publication from Stirling DSDC (Marshall, 2010) concluded that the presence of one person like this should not mean that everyone else loses their right to be out of doors. Deprivation of liberty – that is, keeping someone effectively imprisoned – is a serious issue in itself.

• Advice for othersOpen

  In future, care homes will be more likely to include balconies, roof terraces and roof gardens, as care homes are increasingly multi-storey and designed outdoor space becomes more popular in all kinds of accommodation. There are at least nine important reasons for supporting care home residents to go outside:

  • access to fresh air
  • access to vitamin D
  • it is a basic human right
  • access to bright light, which helps to set the body clock
  • it offers a quiet space
  • it means residents can connect with the outside world
  • it offers a link with the natural environment
  • it offers scope to support mental health
  • it offers potential for activities.

  Key considerations should include:

  • size – the larger the better to accommodate activities
  • climate/microclimate – consider sun/shade and reflected heat
  • outlook – are there views of people and everyday things?
  • materials – non-slip, non-reflective, easy to maintain, same colour as inside if possible
  • access – is it easily accessible from communal areas with a glazed wall to allow observation?
  • detailing – are there highly visible door handles and no high thresholds?
  • balustrades – are these higher than the required minimum of 1.1 metres, slope inwards and appear as normal as possible?

  People with dementia are must more relaxed and confident if what happens around them is familiar – but this will vary from person to person. Some people may have lived in blocks of flats where hanging out washing on the balcony was normal, and where effectively the balcony became an extra room. Generally, a person's physical capacity, creativity, sociability and personal history will shape how they approach and use this type of facility.

• Financial implications  Open

  Affordability depends on the alternatives. Disturbed sleep, falls and disturbing behaviour all have costs, and if these problems are reduced by good design and access to outdoor space, it will save money – including carer burden and the cost of adverse incidents.

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