Improving aged care homes through design

Improving Aged Care Homes Through Design

Thursday, 15 August 2024

Presented by:

Chair:

Marianne Madden

Acting Assistant Secretary, Dementia, Diversity and Design Branch, Department of Health and Aged Care 

Speakers:

Naomi Wilkins
Director, Design and Dementia Support Section, Department of Health and Aged Care

Nick Seemann
Managing Director, Constructive Dialogue Architects and Dementia Training Australia

Liz Fuggle
Associate, Constructive Dialogue Architects and Dementia Training Australia

Angela Raguz
General Manager, Residential Care and Dementia Care, HammondCare

[Opening visual of slide with text saying ‘Australian Government with Crest (logo)’, ‘Department of Health and Aged Care’, ‘Improving aged care homes through design’, ‘agedcareengagement.health.gov.au’]

[The visuals during this webinar are of each speaker presenting in turn via video, with reference to the content of a PowerPoint presentation being played on screen]

Marianne Madden:

Hi everyone and thank you all for attending today’s webinar. I’m Marianne Madden and I’m the Acting Assistant Secretary from the Dementia, Diversity and Design Branch in the Department of Health and Aged Care.

I’ll begin by acknowledging the traditional owners and custodians of the lands on which we are virtually meeting today. I’m based in Melbourne on the lands of the Wurundjeri people of the Kulin nation. I acknowledge and pay respect to their continuing culture and the contribution they make to the life of this city and this region. I also extend that acknowledgment and respect to other families with a connection to this region and any other Aboriginal and Torres Strait Islander people who are with us today.

There will be a question and answer session at the end of the webinar. You can submit questions in the Q&A function on the right hand side of your screen and we will attempt to respond to as many questions as possible. You may need to click on the Q&A icon at the top of your screen to activate the function before submitting any questions. All questions and answers, including the ones that we may not get to today will be published in an FAQ document on our website. We sometimes do get questions that are unclear or perhaps not as directly relevant to the webinar and if we’re unable to answer a question during the session we’ll follow up with the relevant area in the Department and respond through the FAQ document. Also just to reassure you that questions submitted during the registration process have also been considered for the Q&A session. And just finally to note that there’s no option for attendees to turn on their video or microphone.

The webinar slides are now available on our website and this session is being recorded and will be published on our website in the coming days.

So today’s webinar will support you to understand how to adopt the National Aged Care Design Principles and Guidelines. You will hear about what your service can do now to harness the benefits of good design for your residents and workforce. You will hear from Naomi Wilkins from the Department who will present on the important work that we are doing to improve the design of accommodation in residential aged care. We are also joined today by the lead authors of the Principles and Guidelines, Nick Seemann and Liz Fuggle, who will provide us with an overview of the document itself. You will also hear from Angela Raguz from HammondCare who will share their experiences and the benefits of good design. I will now hand over to Naomi Wilkins.

Naomi Wilkins:

Thanks Marianne. So as Marianne mentioned, Naomi Wilkins. I’m the Director of the Design and Dementia Support team here in the Department. So I’ll just start with a very brief overview of why we are doing this work and then I’ll talk a little bit more about next steps towards the end of the presentation.

So as most of you would know the Royal Commission into Aged Care Quality and Safety identified that the built environment can be supportive, familiar and therapeutic or it can be a barrier to independent functioning and a high quality of life. We know that over half of people that are living in residential aged care are living with dementia and that enabling environments benefit people both with and without dementia and that dementia friendly design in aged care makes good design for everyone.

The Royal Commission called for greater awareness and consistency of standards for accessible and dementia friendly design in aged care and recommended that the Australian Government produce a comprehensive set of design principles and guidelines for residential aged care. The Department has developed and published the new National Aged Care Design Principles and Guidelines in response to this recommendation.

So a little bit more about how we got here. We have consulted extensively over the last two and a half years and as you can see on the slide there those consultation activities included everything from discussion papers, surveys, focus groups, an infrastructure stocktake and more recently a design ideas competition. The consultation involved a broad range of stakeholders including older people, their families and carers, the aged care sector, design and technical experts and more. So for those of you who participated in the consultation activities we’d just like to take this opportunity to thank you for all your input as it was invaluable in shaping the document.

To produce the Principles and Guidelines we engaged a consortium team which was led by the University of Wollongong to provide additional expertise. The Principles and Guidelines are underpinned by a solid evidence base and aim to support the development of safe and comfortable living environments that promote independence, function and enjoyment for residents. Throughout our consultations we heard how important it is for residents to maintain their autonomy and to have meaningful engagement. The Principles and Guidelines also aim to provide safe workplaces for staff that support them to deliver high quality care. They represent a shift away from institutional design settings towards environments that are familiar and supportive. The document has been written to allow for flexibility and innovation when designing accommodation solutions. 

So I’ll now pass over to Nick and Liz who will provide an overview of the Principles and Guidelines.

Nick Seemann:

[Visual of slide with text saying ‘Australian Government with Crest (logo)’, ‘Department of Health and Aged Care’, ‘Introduction to the National Aged Care Principles and Guidelines’, ‘and how they can help improve the lives of residents’, ‘Nick Seemann and Liz Fuggle’, ‘Dementia Training Australia’, ‘Constructive Dialogue Architects’, ’15 August 2024’]

Thanks so much Naomi. We’re speaking from Sydney. We’re on the Gadigal land of the Eora nation and we pay our respects to Elders past, present and emerging.

So Liz and I are architects. We’re committed to creating supportive environments and we’ve seen in our lives the incredible difference a good building can make and we’ve increasingly focused on aged care where we see our skills as making the biggest difference. Our practice is about fixing care homes and creating new ones that support quality of life. We see building design as critical to care, not as an add on but really quite central to the delivery of good quality care.

When we were tasked with writing the Design Principles and Guidelines we saw this as having three main components. One was it was to articulate why care home environments matter to the quality of life for the residents. The second one was we were compiling the evidence on what elements would make a difference. And the third element was we were providing a document that would help people to improve the buildings that they already had and to build better ones.

We’re going to give a bit of an introduction to the Principles and Guidelines but before we dive in, a little bit more about how we got there and our backgrounds and how that influenced the work that we do.

Liz Fuggle:

So next slide please. So I was going to tell a story about an experience I had in Scotland. And so Nick said I had to put up a picture of something that was a [0:06:53] of my life there so that’s why we’ve got a Highland cow. I was an architect practicing architecture and in 2010 I was working on the design of an aged care home for men primarily living with alcohol related dementia. And these guys were living in a dark, old, country house, narrow corridors, shared, high ceilinged bedrooms, terrible storage, terrible support for staff. And you’d go into a lounge and all these guys would be sitting round the edges of the room, identical chairs, smoking, looking like they were in this stupor. And we’ve all seen similar situations in many care homes in Australia and internationally but the fear and the atmosphere in those places was palpable. I was actually nervous about going into some of those rooms.

We designed and built a new building in the grounds of that home and this is the first care home I’d worked on which was a household model. It had single bedrooms with ensuites. Eight guys were going to be living in apartments basically with their own kitchens, living rooms and dining spaces and easy access to outside. Big windows, lots of light, wide corridors. There were going to be some amenities like a café and a barber and a pool room, that sort of thing. 

But the real shock to me was that I thought it would take these guys weeks, maybe months to adjust to this new environment and I thought this is going to be a stressful experience moving into this new home. But what was a shock was that almost overnight you could see the change in these guys. So there were fewer fights. There were residents actually making each other cups of tea. Guys that in the time that they’d been in this institution they’d never made themselves a cup of tea, here they were actually offering hospitality to each other. One gentleman’s condition was so improved that he was able to go home after a few months having been living in that institution for several years.

And really what had changed? The staff were the same. It was literally the environment. And I was struck by how easy it was to just transform these gentlemen’s lives to give them dignity. And I thought if the environment was a drug we would be signing up everybody for it. Next slide please.

Nick Seemann:

Okay. So I’m going to talk a little bit about the work of Paul Pholeros who had a big influence on our practice. Paul was an architect who worked on a key project of his, improving the health of Aboriginal people around Australia. Paul died tragically in 2016 and at that point in time his team had worked to improve over 7,000 homes. Since that time another 5,000 homes have been fixed. And when we talk about fixing a home what we’re talking about is the work that they did resulted in demonstrable, measurable improvements in health, a reduction in eye disease, a reduction in skin conditions, a reduction in hospitalisations. And all this was evidenced by long term studies that showed they’d made a change to a building and the effect of that was whatever it was.

The diagram you’ve got there is one of nine healthy living practices they focused on. And Paul really focused on the idea of health hardware. So the healthy living practice here was kids being washed twice a day. And the question was what do you need for that to happen? You need somewhere clean for them to wash. You need a supply of clean water, an ability to heat the water, somewhere for the water to go once it’s been used. And the reality of the buildings that Paul and his team looked at was they didn’t have the hardware. So for all the desire of parents to wash their kids it was actually impossible in the buildings spread across the country. And so the focus was if we fix the health hardware the health outcomes will come.

Now our conversations with Paul were a very big influence that led to the way that we’ve worked and what’s gone into this project. And that was staying focused on health outcomes, what the hardware could do and the way in which that could then translate into what we could do to fix homes rather than just focus on the new ones. So again applying that directly to what we’re looking at in aged care, what we’re saying is for all the will of staff in the world often they’re working against an environment which is actually making it harder for them and is actually making it more challenging for the residents who are living there.

Liz Fuggle:

So when we talk about hardware in terms of the aged care environment this must be driven by the needs of the person living in the home and the staff member working in this home. We know that good care fundamentally comes from knowing the person. And to do this we worked with Dementia Support Australia to create resident and staff personas that are based on real people and then we built a series of scenarios in which real world problems could be addressed by environmental design. 

So this image talks about an activity that somebody could be doing day in, day out prior to moving into aged care, and what is it that that lady needs to do what she’s doing? She needs a kitchen, she needs something to put the biscuits on, all these sorts of things. These are elements that she can’t do it if she doesn’t have those things. And focusing on an experience and how staff and a resident are either involved in what could be a transactional experience or an experience that feels like a normal part of daily life where both people, staff and resident have worth and meaning and dignity in their lives.

So the Principles and Guidelines consolidate decades of international research in a clear and useable format that can support organisations assessing their own buildings, identifying what can be improved and working out how to improve it as well. And the personas help to keep the focus on the person, the people who call the building their home and their workplace. So the audience for the Guide is really broad. So it’s for care staff. It could be used as a training resource on how to understand the building, how it works and how they reset the environment every day to be enabling, and for providers to be inspired, to use it as a design brief as they bring about infrastructure change. It can be for designers to understand better the opportunities and challenges in aged care. And it can be for the consumer to better judge what they should be expecting, what they should be demanding from a care home environment. 

Nick Seemann:

And on the next slide you’ve got one page which picks up on those issues. So the text is quite small here but what Liz was presenting there now comes into a piece of health hardware. So it’s a kitchen. What does a kitchen need to do for it to be something which can actually be a piece of hardware that supports residents, that supports the staff members in turning a meal into a meaningful experience. And so what we’ve got here is we’ve got on the left the personas talking through how they’re seeing the challenges, and once they go through the work on the right the orange box is showing what you can achieve with a change. The diagram in the top right is showing what the aim is with the statement of what you can do to achieve the Guideline. And each one of these was really focused on if we take an idea and we want to just work with that, even if we don’t do everything, if we do one good thing in a building how does that help us to transform the building and through that transform care.

Liz Fuggle:

So on the next slide you’ll see the four principles. And the four principles are recurrent concerns that we’ve found in Australian care homes but they really are also problems globally. Not just Australia but these are issues that we see around the world. They are fundamental to providing good quality of care and they are strongly supported by a wide variety of evidence.

So the first principle in the centre is about enabling the person. And that principle can really be applied in any kind of environment. It could apply to an airport or a bookshop. But it’s key to be thinking about at the beginning of the designing of any type of environment. And it’s about reducing the cognitive burden on the person, bolstering their ability to orientate, to see and hear effectively. It’s about their physical comfort and it’s about general accessibilities. It’s really very basic stuff.

And then the second principle is around cultivating a home. This is about creating spaces in which normal domestic daily life can be lived out meaningfully. So thinking about psychological safety as expressed in the architecture in the form of small scale environments, thinking about privacy that’s built in, so hierarchies of privacy, and spaces that can be made personal, where people feel safe to express themselves through their taste or what they want to do, and having opportunities to do normal domestic things.

The third principle is about accessing the outside, accessing outdoors. This is so basic to physiological health and it’s so often lacking in aged care settings. We know that people often in care homes spend a very small amount of time outdoors once they move into care and this will affect their sleep, their mood and their wellbeing.

And the fourth principle is about connecting with community, about maintaining and improving connections with family and friends at a time of life when this can be much harder and yet it becomes more important. And it’s about having easy things to do and places to go, and about ensuring that people living in aged care are still seen as vitally important and visible citizens to the benefit of our whole Australian society. 

Nick Seemann:

So in the next slide – through the book we’ve got before and after images – we’re going to briefly touch upon those principles. But enabling the person, as Liz was saying, it’s about some basic elements that help us to function. So people are moving into care based on some collection of what we call impairments. They might be cognitive or physical. There’s a reason why it’s not working at home. They’ve moved into care. And what we’ve put forward is that the environment there is either supporting them in overcoming that impairment or it’s actually what turns an impairment into a disability. So what we’d say is that the person is not disabled. It’s the environment which is disabling. It’s turning an impairment into a disability. 

So what we’re seeing in this image as the before image is there’s a lot of noise, there’s clutter, it’s fairly mono, there’s not much change to the environment, it looks institutional, it’s hard to cope with. In the next image we’ve got the same place afterwards. It’s more domestic but what have we done? There’s stronger contrast that helps me to see where a wall finishes and the floor starts. There’s a high level of lighting. There’s a view of the outside that helps me to orient myself. So there’s a range of things that we’re looking at, a whole lot of small things that help to enable somebody in that environment.

Liz Fuggle:

So on the next slide we’re looking at cultivating a home and that is about creating a setting where people can be themselves, about supporting normal domestic life. And the evidence consistently shows that a small scale is key to this, small physical scale that I can navigate easily, that there’s not too many people in the environment for me to have to manage. So throughout the guide there’s many different examples of providers around the country who are doing just this and it’s a key recommendation also of the Royal Commission. I’m sure Angela Raguz is going to go into this in more detail from the perspective of a provider.

So in this principle we’re talking about having a kitchen at the centre at the home, of each of the households, and a focus on functional, short corridors that support resident movement and orientation, and that staff spaces and the trappings of staff are actually outside the household themselves. So close by but hidden so they don’t impair the homely environment of the household. 

Nick Seemann:

In the third principle it’s about the focus on getting outdoors. A key issue of people moving into care is a loss of connection, a loss of mobility to go outdoors. That’s something which we’ve seen from studies that look at how much time do people spend outside when they move into care. And the answer’s not very much. It’s rare for people to actually get outdoors. So since we’re seeing this is fundamental, fundamental to our health, sunlight being important to bone density, the fitness we get from walking around the garden, the affect it has on our sleep patterns, just on our general mental health, this is a fundamental requirement that we have as people. 

And so the problem is often there’s a beautiful garden but people can’t get there easily. So how do we access the outdoors? It’s about we can see where we want to go, we can see how to get there. There’s a door which is identifiable as a door like in that top right image. There are places to sit just outside on the edge of a garden like in that image on the left. And so I can see where I want to go, I can go there, it supports activity, and I can then get back into the home when I want to get back into the home. And again because our focus is on how can we fix existing buildings that have challenges it may not be about making a more beautiful garden. It might be about what you do along the edge of the building to the doors, to those edge spaces, and also the staff coming in with an awareness of if we’re going to activate these spaces we’ve got to pull back the curtains, we’ve got to set up the outside in an inviting way where somebody goes ‘I’m going to go out there for morning tea’ or something like that.

Liz Fuggle:

And then the final principle is about connecting with community through the way that the home fits into the neighbourhood and really invites people in. So overall the Guidelines are aiming to invite and educate designers and providers of what the research and the common experience recommends and to create a pathway towards better outcomes. And it’s really key that these guidelines are not just for new buildings. They’re for every aged care building in Australia. We really reckon that there would be something for everybody. There’s something that everyone can do to improve their environment right now. And the aim is to inspire each reader, each provider to make even small, incremental changes on a trajectory to success. 

This is Mary Marshall on the left who’s one of my heroes and she said this. Good design makes things possible but it doesn’t make things happen. And I just think that’s so key, that it takes engaged leadership, it takes an aligned model of care to really make things happen. And we really hope these Guidelines inspire people to do better and to work with their designers to align their model of care to improve quality of life for everybody. 

Nick Seemann:

So in the final slide we’re just saying that our real hope is that what we’ve done with that image on the left that shows the 31 Guidelines – what we’ve done is taken a large body of information, 30 years’ worth of research, and distilled it down to something which is easier for people to apply. It’s easier for them to apply to a new building if they’re developing a brief. And so we’re thinking of as architects what do we need when we’re designing a new building? It’s easy for somebody to apply one or more of these to an existing building. So the photograph on the right is a building from a number of years ago where we were actually taking this same body of knowledge and seeing what could we do to take an existing building that had probably come towards the end of its life and give it another 10, 15, 20 years in a way that was an affordable investment for the provider, to actually take a building that was institutional and install a resident accessible, resident focused kitchen right at the centre, to improve the access to gardens and to actually deal with all of those enabling elements we were talking about. 

So it’s saying that this is something you can give to your architects, you can work it through with them in order to improve a building. And that small image down the bottom with one, two, three is that DTA through the support from and the funding from the Department has set up a training program that can take you and your team through what you need to do or how you can actually change the building, recognising that the building is part of it, as I’m sure Angela will go through, that staff actually engage in that building in a particular way, is a key way in which we can start to look at how the material is applied. So the material is how do you design a building? That’s your architects. How do you set it up and actually brief your team? That’s for the provider. How do you staff work with it? And the DTA stuff you can see at the DTA website. If you’re in Brisbane we’ve got a masterclass coming up next week that goes a lot more detail into this material. But there’s a whole range of resources that we’ve been setting up to support providers being able to understand and then apply this information.

Liz Fuggle:

So that’s everything we have to say. We’re just very grateful for the opportunity to be involved with the project and we hope it’s an inspiration to all of you. And looking forward to hearing from Angela in a bit about integrating the design and the model of care for success for residents all around the country. Thanks Marianne.

Marianne Madden:

Thanks so much. Thanks Liz. Thanks Nick. As Liz mentioned we’ll now be hearing from Angela who will talk a little bit about what good design in aged care looks like and share HammondCare’s experience particularly using innovative design features in aged care homes. So over to you Angela.

Marianne Madden:

Thank you Marianne. And thank you Liz and Nick. Outstanding setting up. And I was writing a few words down as you were talking. I firstly would say Mary Marshall equally a hero of mine and someone who has been so instrumental in the development of design evidence and those design principles over the last 30 years. And I think what I’m about to talk about, I’m hoping that I don’t repeat too many things for those on the webinar, because there’s a strong alignment between the buildings that HammondCare’s been building over the last 30 years and what is now sort of culminating in these Guidelines which I think are a fantastic addition to what we’re able to think about in the aged care landscape.

So in terms of HammondCare we’ve been operating the small cottage household model since the mid-1990s. So it is literally 30 years. And giving a lot away I have been a part of that for that complete 30 years. So I’ve been very involved in the operation of homes that are small, domestic, familiar, operating within that cottage model, and working with our research teams, the Dementia Centre and our architects over many years in order to embed those principles into the built form.

What I wanted to do today was a little bit of two things. One to just reinforce some of the things that Nick and Liz talked about, being what are the fundamental things that underpin those principles and how do we apply those within the cottage model which is purpose built. But I also wanted to share some examples within HammondCare of how we’ve sort of taken some of the principles and been able to apply those to the non-purpose built environments in the case of where we’ve had an acquisition or in some instances if we’ve been building these for 30 years, HammondCare’s been around for 92 years, not all of our built forms magically sort of translated to being in that cottage model. So there’s had to be some refurbishing, adjusting of environments that are perhaps a little bit less intuitively the design that we’re talking about. So I just wanted to give some practical examples of where we’ve been able to make inroads and I guess what are the ways that we look at that and think about what things can make the biggest impact and be achievable.

So what does good design look like? Well you’ve heard from Liz, you’ve heard from Nick. But it is about – I have a really simple way of explaining it. If I see it in my home then I expect to be able to see it in a person’s home who is living within an aged care environment. Equally if I don’t see it in my home then I absolutely must question why is it appearing in a resident’s home? So that for me is that basis where you start to think about how do you de-institutionalise an environment? Because even though you can build great small cottages, but if we fill them with institutional relics like staff noticeboards or signage that is really not something that you would see in your own home or we line corridors with equipment, the linen skips or lifting machines or dressing trolleys, or we have sort of boxes of gloves everywhere, you start to, I call it, institutional creep. And so that’s the first thing, the lens. And this can be done I think in many aged care homes regardless of what the core underlying build is, is just taking stock of what do we see when we walk through a home and are they the same things that we would see if we walked through our home?

When we talk about domestic and familiar, two parts to that. One is the scale. Smaller is always better and we know that that’s been recommended by the Royal Commission. But it’s equally not easy to just turn on where there are buildings that have been around for 25 years of their 40 year life. How do we try and think about the small within the large if that’s what we’re faced with? The familiar component, I believe that sometimes people get confused and think that that needs to be era specific and so we try and sometimes design for generations. And that can be limiting because not everybody sort of has the same tastes, not everybody has the same – we see generations change. If we go through and you think 30 years there will be generation change. So it's not era specific as much as it is about things being familiar. And this does come through the Guidelines put together through Liz and Nick. A toaster needs to look like a toaster. A fridge needs to look like a domestic fridge. If we’ve got a stereo system or a CD player it needs to be something that people can see that looks like a CD player, not sort of music coming from somewhere or something that looks like a spaceship. They’re the things that start to undermine that concept of home and things being familiar, but not necessarily the taste of everyone. 

And that’s a big question that we get asked at HammondCare is how do you cater for all people’s different tastes, or that home doesn’t look like my home did. And the response is it’s about the familiarity and about people understanding that that belongs within the home and then being able to think about the way that staff and others use the environment, which then creates that engagement to be able to function as a home. Next slide please.

And these are things that come from a new build. So those providers that have got the opportunity to build a greenfield site, to go ‘Here we go. We’ve got a beautiful block of land. We can build brand new’, the way that those design Guidelines are interpreted there’s some really important things to think about. And that’s where I guess you do get to think about how do we innovatively meet some of those guidelines. So what HammondCare has done – and you can see the photo on the right – we fondly call that the Harry Potter door. And the Harry Potter door is really the transition between where you will find all of those institutional things that are needed in order to support the care of residents within a care home but they are not lining the corridors, and they are in a back of house area that is closely located to the cottage but it means that staff can be in and out in an unobtrusive way to bring those things in that they need in order to support the residents within their care, but also where those things that they don’t need to be looking at all day every day – and I will say this. They don’t need to be looking at or smelling – can be in the back of house, they’re out of the way, and a resident doesn’t need to see a whole range of different people walking in and out of their home trying to get those things in and out. 

So it’s unobtrusive. It’s about reducing that unwanted stimulation. It’s about thinking through how do we use what we need, how do we support the staff to have quick access, but that we’re not cluttering the domestic and familiar environment, and to be frank, institutionalising it.

Another element that I think is really important is how do we use technology within any new builds? And so sometimes innovative features and what you will see or what you won’t see in these pictures is annunciator boards and places where the nurse call is buzzing and whizzing letting us know who requires assistance. But that doesn’t mean that it doesn’t exist. And so a way of thinking about reducing unwanted stimulation in many care homes may be just as simple as thinking how can we work with our nurse call systems so that we can alert staff in a way that doesn’t disturb the environment or people within it, doesn’t add to the noise, doesn’t add to the potential for people to be either agitated or irritated by seeing the lights flashing or hearing the buzzing going. That’s a simple way and an innovative way to be able to change an environment to reduce that unwanted stimulation which can sometimes be quite distracting for residents, and also to be honest can be something that staff start to become immune to and don’t always hear or see and it just adds to the noise within an environment.

So if we think about the corridors and the length of corridors and the orientation of corridors, the saying that I have is we want people to see or sense where they want to go. And that gives people access which sometimes is only focused on from a resident perspective, being able to see or sense where I want to go. We don’t always think about it in terms of staff. It’s just as important for staff to be able to see and support by being able to actively scan an environment and see where residents are. Are people choosing to spend time in the private spaces or in the community spaces? And having the kitchen at the centre of the family home is a good way of being able to sort of focus that that’s the way that both visual access comes in but equally for staff who may spend time in the kitchen as they’re supporting residents to prepare lunch, prepare dinner, they’re able to scan and see down those corridors to the outdoor areas, to those common living areas. And that means that they can support residents unobtrusively. It’s not always about telling people where they would like to go. The environment can support that by being intuitive and enabling. Next slide.

So this again is not designed for people to sort of try and put on their glasses and read. Really all it’s trying to say is that the small household model does have evidence behind it. The most recent is the clustered and domestic residential care in Australia study that was done – I think that was done or published in about I’m going to say 2018/2019, around the time that the Royal Commission was going on. And what it demonstrated was that the environment is one aspect, and I think that’s a really important thing to focus on. With the small household model the environment is one tool but the way that we support staff and residents in the social environment, which is just as important as the physical environment, when we think about the way that Liz or Nick, one of the two made the comment of we all know that good care comes from knowing and understanding the person, this brings together both the environment, the model of empowered care staff who know the person who they are providing care for, flexible models and using the household as a complete household. So cooking being done within each of those small cottages with the multi-skilled care workers and residents is a vital part of engaging people in something that makes them feel like they belong. It’s not sort of create a kitchen but then don’t use it. It’s how do we incorporate the kitchen into daily life and normalise things for the people who are living in the care home rather than a magic bain-marie appearing at sort of 8:00, 12:00 and 5:00, and then we contradict ourselves by saying to staff ‘Can you be flexible? Can you do things in a flexible way? People can have breakfast or lunch when they want and how they want’. It’s very tricky to do that if you don’t set the structures up to be able to support that. 

But that study in itself showed (a) the cost of care to the whole system. It actually costs less to provide people care within the small, clustered, domestic and familiar model than it does in the larger models. The outcomes for residents, it demonstrated that they were less likely to be using inappropriate antipsychotics and psychotropic medication. They were less likely to be hospitalised inappropriately and were more likely to report higher levels of quality of life and quality of care. So ultimately the arguments are strong to support the small household model. Next slide.

Now I think this basically just says everything that I said in the last slide so we won’t spent too much time on this one. So those increases in a person’s wellbeing and the reduction in adverse outcomes. We all know for older people who are living in care homes, the worst place that they can end up is in the emergency department. So anything that we can do to the environment and to our models to support people to be cared for in their own homes and to have a less likelihood of those hospital presentations, that can only be a positive. Next slide.

So this is an example of a transformation. And I did say at the beginning that it wasn’t just about the greenfields. So this is a true before and after for a care home that HammondCare acquired that had sort of those serveries if you like, that it was a space where main kitchens would deliver the meals and that was where a dining room sat off that. And we really looked at it and thought can we do everything? And the answer is probably not. But there were some things that we could do which was make it more inviting, create a space that reads as a kitchen, open that up and just put in a couple of simple appliances that we say we can’t actually cook all of the meals in this nursing home every day, but can we cook morning tea, can we cook afternoon tea, can we cook a buffet style breakfast, and as Liz and Nick said incrementally move towards improving the environment in order to enable people to engage with it more. So that’s a real life example of somewhere that – and it can be done cost effectively. You can see the shape and form is not changed. It’s not major structural change, but it’s just improving that amenity and the contrast for people to be able to see it, identify it, use it and enable people to have a little bit more control over their own environment. Next slide.

This is the same home. And I’m sure many of you are familiar with the nice interior brick corridors. I think this was an 80s special and then probably extended into the 90s, that a lot of homes were built with brick interiors. And what that does is really darken the space. And you can see what we did was really just lined the walls, repainted and painted doors in order to ensure that they were identifiable, that we used the contrast, recarpeted and looked at how we could improve the lighting so that we didn’t end up with pools and shadows but rather ended up with a space that was just calmer, nicer, more visually pleasing, but also identifying the things that we want people to identify and minimising those things that weren’t adding value for the people who were living in the home. So next.

And really hopefully from this providers have seen that there’s opportunities to improve the space. Ideally it’s using the principles as a starting point to say how can we incorporate them into our thinking and what small changes can we make that can have a big impact. And then if you’re building a new home starting from scratch and really utilising those Guidelines because the outcomes for the people that you serve will be a lot better as a result.

And I would like to thank everyone for the invitation to be at this webinar. So back to you Naomi.

Naomi Wilkins:

Thank you Angela and to Nick and Liz as well. Between you obviously a wealth of experience in design but also in the importance of that supporting model of care. And it’s great to see and hear those practical examples particularly for the existing older stock.

So I’ll just talk quickly a little bit more about next steps from here. The Principles and Guidelines are being introduced on a voluntary basis. We’re encouraging providers to consider where they might implement practical changes from the document to improve design for the benefit of both residents and staff. The Principles and Guidelines can be applied to aged care settings at various stages of the development like Angela just touched on there, so from minor upgrades through to more significant refurbishments and new builds also. They include design features that range from simple, low cost changes that can be introduced to existing aged care homes through to more substantial features that better suit new buildings.

The Department will be monitoring the level of uptake in the sector and that’s to help us really inform the approach that might be needed in the future, including whether any sort of regulation might be required going forward. We’re also working with the Australian Building Codes Board just to consider whether any elements of the Principles and Guidelines could lend themselves to incorporation into the National Construction Code in the future.

We have also published a range of supporting documents on our website including fact sheets for different audiences and a summary of the Principles and Guidelines. We’re developing resources to support aged care providers and staff to adopt the Principles and Guidelines. This includes an assessment tool that we have been working with Nick on to help providers review their aged care homes to determine the extent to which they meet the Principles and Guidelines and to help them with those planning arrangements.

We also have the Aged Care Capital Assistance Program and I think I’ve seen a few sort of questions fly into the chat there about what funding is available. So ACCAP is an ongoing program that provides grants to build, extend or upgrade aged care services or to build staff accommodation where older people have limited or no access. Organisations can apply through the grant rounds and eligible activities are determined on a round by round basis of course, with details provided in the Grant Opportunity Guidelines. 

There is a current ACCAP grant opportunity open for infrastructure projects that focus on maintaining or improving access to quality residential based aged care services and that’s for older people living in all regional, rural and remote locations and First Nations people in any location including metropolitan areas. The current round expects applicants to align their proposals where possible with the Principles and Guidelines and going forward we’ll be continuing to look at opportunities to link those Principles and Guidelines with relevant aged care funding rounds including by asking applicants to demonstrate how their proposals will adopt the Guidelines. So applications for that round close on the 29th of August at 2:00pm and you can find some more information just by searching for Aged Care Capital Assistance Program on our website.

As I mentioned earlier the Department also recently ran the reimagining where we live aged care design ideas competition to test and promote awareness of the draft Principles and Guidelines. As you can see from some of the illustrations here entrants applied the Principles and Guidelines to create home-like environments that promote quality of life, enjoyment, wellbeing and connection to the community. You will see there’s a little video on the slide there that we were going to play but we’re sort of a bit pressed for time and we want to get some questions in. So you can see the full video on the design ideas and concept designs that were generated from the competition by searching ‘Reimagining where we live’ on the Department’s website or I might suggest that if someone can we pop a link into the Q&A chat to the website too.

And then there’s just a reminder there on the slide for more information and where to find the resources I mentioned earlier. So you can just visit the website health.gov.au and use the search term ‘Improving accommodation in residential aged care’ and you should find some of that information. 

I’ll now hand back to Marianne. I think we’ve got about ten minutes for Q&As.

Marianne Madden:

Yeah. Great. Thanks Naomi. And yes you’re right. We’ve got about ten minutes for questions. And I think people will have seen questions popping up in the chat. So I’m joined back again by Nick, Liz and Angela and of course Naomi to work our way through those. It’s a little bit of a mix of questions that have been submitted in advance and also ones that have been asked during the presentation. So I’ll try and do a little bit of a mix of both when I’m handing over to others. So Naomi I might start with you just around – I think there’s a couple of questions that just go a little bit to cost of implementing changes and just around sort of reflections on that, and maybe also to Nick and Liz as well about I suppose that interaction between kind of the cost to providers of making these changes and thinking about the context in which they’re operating. So I might hand to you first Naomi.

Naomi Wilkins:

Sure. So yeah, like I mentioned the Principles and Guidelines have been written to allow for flexibility and innovation when designing those accommodation solutions, and they range from those simple low cost changes that can be introduced to existing aged care homes to more substantial features that would better suit new builds. So we know that even relatively small and inexpensive changes to existing homes can make a meaningful difference like we’ve heard about today and can improve that wellbeing and quality of life for residents but also provide better work environments for staff.

So I think in particular the Guidelines associated with principle one I would say require little additional cost if they’re incorporated during both the design of a new building but also easiest to apply retrospectively to existing buildings. And some of those suggestions require changes to organisational practices, so through decluttering programs. Some can be achieved without construction work just through upgrading furniture, and some could be achieved through routine maintenance programs such as renewing the flooring.

I think we encourage all providers to engage with the Principles and Guidelines and consider the many ways they might be able to make those practical changes. But we also acknowledge that there’s a lot of pressure on the sector with the other reforms which I think some of those questions have touched on as well. So Nick did you have anything to add to that one?

Nick Seemann:

Look I’ll say something there and I’d be interested in Angela talking about some things that were in the Suzanne Dyer paper that she was talking about as well. Look we’ve worked on projects that range from literally a $60,000 contribution to change an institutional environment through to much, much larger projects of multimillion dollar fixes to aged care buildings. We’ve got one client who we’re doing a major piece of work for at the moment who repeatedly says to the builders and everybody involved while it might not seem that way the cost of the building is a small part of the cost of running a home. And so he keeps going through the fact that he wants to spend the money now in order to get the building right because he will recoup in terms of what it means for the staff later.

And so a lot of what we’ve done with Principles and Guidelines were how do we do things that make the staff life easier, therefore it makes it easier for them to actually support residents. That last image which we showed of a building where we’d changed a building, the building was basically at the end of its life. The work that we did was about a third of the cost of replacing it with a new building. So it wasn’t perfect. There were compromises about what could be done within the shell of the existing building but for a third of the cost of replacing that building the provider got a very functional building that was very close to everything that we’ve been talking about.

Angela do you want to talk about some of the work that you’ve looked at there?

Angela Raguz:

Yeah. Look as I said we’ve been building the buildings for over 30 years and over the life of the building there is absolutely no doubt that it is a cost effect option. Big part about it is how you operate it though. So I know that if you’re running a site that has a standalone kitchen for example that’s a big capital investment. To build a standalone kitchen you’re paying sort of – I don’t know. I’m going to call out it’s millions of dollars to build it but I know that it’s over a million dollars a year to run it. But then when you amortise that, where you sort of have smaller, domestic kitchens, the cost is less. We have far less food wastage if you think about the amount of food that comes out of large kitchens. When you’re in a small kitchen it does rely on having small numbers of residents though to be able to cater to those individual needs in the same way that you would at home. So those costs over time are a lower cost. You do have to maintain the environment though. You have to maintain all environments. 

And so thinking about your depreciation schedules and how and when things are replaced on those schedules, I think one of the challenges in this sector is that not everywhere is sort of invested in that same way in buildings over many years, and so it’s all in one hit and it feels very expensive. And so you’re right. There is that expense, but it’s about incremental. And I think that’s the message I’m hearing, is I don’t think anyone’s expecting that you go away and knock down and rebuild all aged care in this model. And decluttering is a first step to be able to think about what do we see when we walk in. And I’m a strong proponent of decluttering signage. Now I know there’s probably some colleagues online that would say but we’ll get in trouble because you’ve got to have the sign up. Somebody expects it. Really argue that back to say if it’s about signage for staff, where are our staff spaces? Are there staffrooms? Are there staff communication channels? How can we get the messages to staff in a way that doesn’t institutionalise someone’s home? It doesn’t have to be an expensive starting point is I think what I would say.

Marianne Madden:

Thanks. Thanks Angela. That’s really interesting. And I was wondering Nick and Liz, sort of building on that point, I know there’s been some questions in the chat around that balance between I suppose the homely environment versus some of that functionality as a workplace and some of the kind of requirements around safety and other things, and I suppose how the Principles and Guidelines sort of tackle that balance. 

Liz Fuggle:

And I think that’s absolutely key that the two have to go hand in hand. The way we’ve approached it is really through experience of seeing things done cleverly in other environments, that you can provide wash hand basins in a discrete way and you can provide safe flooring with a homely appearance. I mean it’s 2024. There’s a lot of good technology out there that can support excellent clinical care in a discrete way. It’s just we have to be a bit clever about it. We have to think about it like Angela’s saying in an incremental way and tackle each problem one at a time and deal with it using design. So I think all situations we can work through. It’s just about step by step improving the environment.

Marianne Madden:

Thanks for that Liz. I know there was a little bit of hands up interest in the online question and answers around the information about the masterclass that you mentioned Nick next week and I thought I might use the opportunity to ask you about that because it’s probably something people would like to know about immediately.

Nick Seemann:

So we ran masterclasses last year through DTA. We ran six last year. We’re running three this year. One’s in Brisbane, which is the one next week on Thursday. There’s one that’s going to be in Perth and one that’s going to be in Melbourne. So basically it’s masterclasses where people come along for a day and we run through a lot of this material and a lot of how do we assess an environment to find out what’s good and what’s bad in that environment and how do we essentially diagnose what we can actually do to fix something and charter a pathway to that. So that’s a program where there are still spaces. You can come along in Brisbane next week, or if you’re in Perth or Melbourne the months that follow have got more masterclasses. And it’s a really great program so please come along. 

Marianne Madden:

Yeah. Great. And we will as we mentioned at the beginning make sure we have responses to all of the questions that are asked and we’ll pop that on the website. Nick is there any website that people should go to just in terms of those masterclasses and that other sort of support available?

Nick Seemann:

Look the DTA website which is a simple one, dta.com.au, has got a lot of information about the programs that we do where we’ve been working with the Department to set up a series of programs so that with the release of these Principles and Guidelines our Environments team has a lot of support. So as well as the masterclass we’ve got programs where we actually go and work with staff so that the staff are really aware of what they can do in their existing buildings in order to declutter or in order to set up meaningful activities or working within what they’ve got to make meals better, things like that. So there’s a full range of different programs that we’re running there.

Marianne Madden:

Excellent. So as I said we’ll make sure that all of those links are in the Q&A responses that we pop up on the website. So I think we’re almost at time. So before we do close and I formally thank our presenters I just note that there is a link in the questions and answers to a webinar survey. So we’re really keen to understand how we can improve our webinars. So you can scan the QR code and also access the link in the Q&A. So it will only be about a minute to answer three questions so it would be great if people could do that.

But otherwise I’d like to thank our presenters for their really interesting presentations and for the answers to the questions. I’d also finally like to finish off by thanking everyone for their attendance today. We’re really hopeful that you found it a useful session. And keep your eye out for the additional information that will come out after the session. So thank you everyone.

[Closing visual of slide with text saying ‘Australian Government with Crest (logo)’, ‘Department of Health and Aged Care’, ‘Webinar survey’, ‘Thank you for attending today’s webinar’, ‘Please provide your feedback by answering 3 short questions’, with image of QR code, ‘agedcareengagement.health.gov.au’, ‘15 August 2024’]