Contents

Foreword

Acknowledgments

Introduction

Part I: Australian Schemes

Chapter 1: A Study of Sir Montefiore Home Randwick

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 2: A Study of Southwood Nursing Home

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 3: A Study of Wintringham Port Melbourne Hostel

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 4: A Study of Tjilpi Pampaku Ngura

Geographics

Care

Neighborhood Integration

Staffing and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 5: A Study of Brightwater Onslow Gardens

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Part II: Japanese Schemes

Chapter 6: A Study of Akasaki-cho Day Care (Kikuta)

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 7: A Study of Himawari Group Home

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 8: A Study of NPO Group Fuji

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 9: A Study of Gojikara Village

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 10: A Study of Tenjin no Mori

Geographics

Care

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Part III: Swedish Schemes

Chapter 11: A Study of Neptuna

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Part IV: Danish Schemes

Chapter 12: A Study of Salem Nursing Home

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Part V: The Netherlands Schemes

Chapter 13: A Study of Wiekslag Boerenstreek

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 14: A Study of Wiekslag Krabbelaan

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 15: A Study of De Hogeweyk

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 16: A Study of Weidevogelhof

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Part VI: United Kingdom Schemes

Chapter 17: A Study of Belong Atherton

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 18: A Study of Heald Farm Court

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environment Sustainability

Outdoor Living

Chapter 19: A Study of Sandford Station

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 20: A Study of the Brook Coleraine

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Part VII: United States Schemes

Chapter 21: A Study of Leonard Florence Center for Living

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 22: A Study of the Skilled Nursing Component at Foulkeways at Gwynedd

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 23: A Study of Deupree Cottages

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 24: A Study of Montgomery Place

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 25: A Study of Park Homes at Parkside

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Chapter 26: A Study of Childers Place

Geographics

Care

Neighborhood Integration

Staff and Volunteers

Environmental Sustainability

Outdoor Living

Conclusions

Definitions

Index

Copyright © 2012 by John Wiley & Sons, Inc. All rights reserved

Published by John Wiley & Sons, Inc., Hoboken, New Jersey

Published simultaneously in Canada

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Library of Congress Cataloging-in-Publication Data

Design for aging : international case studies of building and program / Jeffrey Anderzhon . . . [et al.].

p. cm. — (Wiley series in healthcare and senior living design)

Includes index.

ISBN 978-0-470-94672-5 (cloth : alk. paper); 978-1-118-17385-5 (ebk); 978-1-118-17386-2 (ebk); 978-1-118-17976-5 (ebk); 978-1-118-17977-2 (ebk); 978-1-118-17978-9 (ebk)

1. Barrier-free design for older people—Case studies. I. Anderzhon, Jeffrey W. II. Title: International case studies of building and program.

NA2545.A3D46 2012

720.84’6—dc23

2011031423

Foreword

By Mary Marshall, MBE, MA, DSA, DASS, Emeritus Professor, University of Stirling, Stirling, Scotland, United Kingdom

An aging population is something you can plan for. It need never be a surprise. As a person born at the start of the British baby boom in 1945, I have always known that I belonged to a very large cohort who put a strain initially on the schools and then on homes to live in and now on pensions. We are beginning to have all the impairments of aging such as deteriorating mobility, eyesight, and hearing, and this will get worse. As we age, we can also expect a good number of us to get dementia. This bulge of the population has been known about as long as we have been alive, although the cohort ahead of us have lived longer than expected, which means that if we do too, there will be a larger number of us reaching really old age than could have been planned until recently. This baby bulge is a phenomenon in all industrialized countries and will be seen in almost all countries of the world before long. What could not have been planned for is the fact that we had fewer children than our parents and this fall in the birth rate has continued.

The point I am trying to make is that we could and should have been planning for large numbers of older people for many years. Instead, people behave as if it is a sudden event—anything less sudden is hard to imagine. You have to assume that it has been in the “too difficult” basket of most decision makers for a long time. Certainly the fact that a lot of very old people get dementia has been. The sudden realization of the aging population means that it is often labeled a “problem” or a “burden” on society, which is nonsense. It is an amazing public health achievement. It means that babies started to survive infancy and all the illnesses that used to kill children. It also means that we now have a cohort of people who are skilled and experienced and can continue to make a real contribution to society. However, a proportion will find their impairments overwhelming and their families and friends will not be able to support them to remain at home, however much care in the community is available. Alternatives will be required, and this book is about the buildings in which they will live.

In all societies alternatives to home involve communal living of some sort going from small flats with intensive support to hospitals. The largest number of buildings will be care homes (a term we use in Scotland for our homes that combine residential and nursing homes). These are a challenge to design as well as a challenge to run. Communal living is the choice of very few people; perhaps only those who have lived communally all their lives. This book is about designing the best possible buildings that maximize privacy, choice, and independence while making it easy for peoples’ needs to be met. They are also places where staff work, so they must provide a congenial work environment in which staff members feel valued and that their needs have been met, too. These buildings also have to be flexible since we are all so different in what we want from our home and each cohort using the building will have different attitudes and preferences.

Collections of examples of good buildings are a great way of influencing others. They provide an engaging story about a building and details for every kind of reader. As far as designing specifically for people with dementia, Cohen and Day produced their excellent book of case examples in 1993. This book had huge influence. I have, for example, taught in many design schools when we looked at examples from this book. It also inspired Peter Phippen, Stephen Judd, and me to collect 20 case studies for a book published in 1998 to be followed by Damian Utton’s collection in 2007, when ours sold the full print run. These well-used books will now be enhanced by the collection in this book, which has a wider remit of covering buildings for older people generally as well as those with dementia. Given that the majority of older people in care homes have dementia (60 percent of residents in English nursing homes had dementia in 2007, National Audit Office), it is important that all facilities for older people are dementia-friendly.

There are many particularly interesting aspects to this collection. One is the range of countries from which examples are drawn. The Japanese examples in particular will underline the differences that arise from different cultural traditions. Another is the range of examples within countries. The Australian examples include one for indigenous Australians who need very different things from buildings and another for older homeless people who have particular needs. De Hogewejk in the Netherlands aims to provide for people from very different backgrounds in one building. This acknowledgment of lifestyle differences, as well as cultural differences, is rare and to be welcomed as an example to learn from. Another welcome focus is on outside space; the design of which is only beginning to get the attention it deserves.

This book will be immensely useful for a wide audience. The detail in the case studies will be helpful for commissioners, planners, and providers. Professions such as architects and designers will see it as an invaluable resource. Learning from the best can only enhance practice because it sets a benchmark. What we need more than anything in this field is higher expectations. This book makes an invaluable contribution.

REFERENCES

Cohen, U., and K. Day (1993). Contemporary Environments for People with Dementia, Maryland: John Hopkins University Press.

Judd, S., M. Marshall, and P. Phippen (1998). Design for Dementia. London: Hawker Publications Limited.

National Audit Office (2007). Improving Services and Support for People with Dementia. London, The Stationary Office.

Utton, D. (2007). “Designing Homes for People with Dementia.” Journal of Dementia Care, London.

Acknowledgments

This book could not have been possible without the support of numerous individuals who graciously agreed to assist in both large and small ways. To all of these individuals we owe much gratitude.

The massive editing chores completed by Linda Anderzhon were “spot on.” She added clarity and consistency to the work with little reward and less grumbling. Without that assistance, we would have words but certainly no book.

In England, Jane Hughes, Alison Thomas, Jane Mahon, Damian Utton, and Denise Giblin not only provided wonderful graphics and critical input, but were of wonderful assistance in the organization of multiple electronic files for the manuscript.

Kate Sarkodee has been a sterling support in the development and collation of the material and photographs for the Australian studies as well as for two of the Japanese case studies. Kirsty Bennett, Maureen Arch, Doug McManus, and John Wilson helped enormously with the Tjilpi Pampaku study. Kikuta and Himawari are two studies that could not have been published without the wonderful support of Hideo Abe. Rosemary Norris kept Stephen Judd on track, as always, for which we thank her.

Introduction

It is stating the obvious that the populations of the developing countries are aging and that this is having significant impacts on their economies and their societies. If the second half of the twentieth century focused on the education of the baby boomers, the first half of the twenty-first century will be about funding their health and aged care and about housing this population.

How countries will pay for the health and care costs of an aging society is a question that is occupying center stage within the political debate in many countries. In Japan, Long-term Care Insurance was introduced in 2000; in the United States, in early 2010 a signature and controversial health-care reform legislation for the Obama administration was initiated to broaden health insurance coverage; in Australia, the federal Labor government has wrestled with the states on how to pay for health and aged-care services. In Europe, the demographics are the same but the responses have been different: Governments that have previously fully funded health and aged care are now seeking greater private funding of these costs. The impending costs of health and aged care over the next 40 years are something that no country can ignore and for which all countries must now prepare.

This impending need has generated new ideas and new ways of providing aged care. There has been increasing choice in the type, nature, and complexity of services that are delivered within the home. This has meant that fewer people are being prematurely admitted into all forms of residential aged care. But while at-home community care is crucial, it cannot be the only option or solution. The demand for more residential aged care facilities, skilled nursing homes, assisted living, or similar congregate housing that are places where both accommodation and care services are delivered is increasing at a rapid rate and will undoubtedly continue to do so at least in the near term.

At the same time, as the numbers of older persons with higher dependencies are increasing dramatically, there has been a fundamental rethink about the style and nature of those services and the built environment in which those services are housed. There is recognition that these places are not medical institutions, though they need increasing medical supports to address the cognitive and physical conditions of their residents. There is increasing recognition that the “facilities” are not institutions but people’s homes. Unlike a hospital or a hotel, people do not visit them for days, but they come to live, sometimes for years. But these are also places where the care staff work and are charged with providing quality care for the residents. The challenge we all have as designers, care providers, or simply members of society is how to express the competing needs of “home” and “care delivery” in both the physical and social environment, so that the residents feel they belong while at the same time delivering as effective and efficient care as possible.

It is not surprising that, in a search for answers to this challenge, there have been quite a number of shibboleths that methodologies have been peddled, and that “solutions” have been trademarked. The common thread has been a recognition that the physical and the social environment must work together to create an environment that facilitates better care for the older person within an environment that at least replicates home.

These are not abstract concepts. This is a question of where your mom or dad might live their last years or, indeed, where you might live your last years should you need care. These are realities that individuals and, indeed, societies, face on a daily basis and, with the world population demographics we face, will be realities that assume more urgency.

This book brings together 26 case studies of excellent aged-care environments from seven countries: Australia, Japan, Sweden, Denmark, the Netherlands, the United Kingdom and the United States. The authors do not suggest that it is an exhaustive selection or, indeed, that the 26 case studies are the very best services or designs from each country. We hope, however, that this work will stimulate further investigation, presentation, and discussion from around the world.

However, these examples do share two commitments. The first commitment is that the physical environment is an integral part of the care being delivered: Effective residential aged-care environments must be both therapeutic, promoting resident improvement, and prosthetic, compensating for physical or cognitive dysfunction.

The second commitment is to the idea of belonging. “Home” is a much used and abused word in aged care and in designing for older people. What do we mean by home? How do we know when we’ve found it?

The American author Frederick Buechner, in his book The Longing for Home, says:

The word home summons up a place—more specifically a house within that place—which you have rich and complex feelings about, a place where you feel, or did feel once, uniquely at home, which is to say a place where you feel you belong and which in some sense belongs to you, a place where you feel that all is somehow ultimately well even if things aren’t going all that well at any given moment.1

These case studies share a common commitment and focus on the person and an appreciation of what is important for that individual, within their culture, so that they have the greatest opportunity to feel that they belong. What suits the older American in an urban environment will most certainly not be appropriate for the Australian Aboriginal in the remote deserts of Australia. What has been designed as a memory village for 140 Dutch residents with dementia would most certainly be inappropriate for the residents of the group home in Japan. But while the designs and the care programs of all 26 case studies are very different, all of these case studies are environments in which older people belong and one in which they can feel truly at home. We hope that you are inspired by them.

1 Buechner, F. (1996). The Longing for Home, Recollections and Reflections, San Francisco: Harper Collins, p. 7.

Part I

Australian Schemes

Chapter 1

A Study of Sir Montefiore Home Randwick

REASONS FOR INCLUSION OF THIS SCHEME

• Sir Moses Montefiore is committed to the respect of elders within a distinctly Jewish cultural tradition.
• This scheme is one of the largest and most expensive residential aged care services in Australia.
• The multistoried building was designed on a strict grid system.
• The scheme is a very large residential aged carebuilding that has minimal overtones of institutionalism.
• The facility boasts more than 500 volunteers who provide community engagement.

Geographics

Vernacular Design

How does the scheme/environment respond to the locality?

Although the Montefiore scheme is very large, the design team has attempted to deinstitutionalize its aesthetic. For example, a mixture of materials has been used on the building’s façade and includes understated signage. Because the majority of the garden areas are inwardly focused, created by the building itself, there is no street view of resident activity. This provides a quiet setting for the community, but at the risk of the Home seemingly trying to protect itself from the surrounding world. This feeling is exacerbated by both the size of the building and by a surrounding fence and heavy landscaping creating an almost fortress-like feeling. So large is Montefiore that the operator and design team refer to it as an “urban precinct” rather than a building.

Three distinctly different urban areas surround the Home’s site. To the north is a low-scale historically protected residential area separated from the site by a narrow street. Medium-density housing of varying scales occupies the east and south. The western boundary of the site adjoins a precinct for large-scale development including low-rise housing and university workshops. The site’s natural topography has been used to lessen the impact of the five-story structure. A two- or three-story building is presented to the residential flanks on the east depending on where the residential neighbor is located, south and north, while the five stories look over the university workshops. The scheme successfully negotiates between the changing contexts, and in this way respects the surrounding streetscape, but maximizes the development potential of the site.

The grid design used by the designers is the driving force behind the building’s layout. This fairly rigid design has limited variety with a repetitive pattern of windows due to the module room design. The façade would have been relentlessly institutional if not for the clever mixed use of a variety of materials to reflect the streetscape and reduce the exterior scale of the façade. Brickwork and painted panels mirror the residential housing and the building corners relate in a more formal manner to the nearby university buildings using glass and metal mullions. A mark of its success is that a residential development adjacent to the site, which was designed after the Home, has clearly integrated the vernacular design of the Home into its own architecture.

Care

Philosophy of Care

What is the operators’ philosophy and how does the building match this philosophy?

The philosophy of Sir Moses Montefiore Homes is “to enhance the Quality of Life of the Jewish Aged Community by providing an exceptional standard of service and care, and embracing the richness of Jewish Culture and Tradition.” Quite simply, Montefiore Home is committed to respecting their elders and providing the very best for them within a Jewish cultural tradition. Therefore, the design brief included the charge to the architects to build a flagship for high-quality residential aged care in Australia. There was a strong focus on excellence and quality with costs being a tertiary consideration. The design process was lengthy, beginning in 2000, and saw a remarkable attention to detail by the design team. Design solutions and interior design approaches were explored in depth, including the construction of mock-up resident rooms in the basement of another of the operator’s facilities in order to test sizing and finishes. Chief Executive Officer Robert Orie stated: “We wanted to get it right. We were building for 50 years, so we were asking ourselves, ‘What would we want when we reach this stage of life?’ ” The result is perhaps the most expensive building of this type in Australia. Resident rooms are nearly double the required size as a way to preempt any future regulatory changes; interior design selections, finishes, and furnishings are “upscale” and of high quality; food services are comparable to any fine restaurant dining and there is a comprehensive social program.

The executive team was inspired by a research study1 that significantly influenced the development of the philosophy of care, and, in its turn, the design of the building. The study found that there are 11 critical elements of quality of life: comfort, privacy, dignity, individuality, autonomy, spiritual well-being, security, relationships, functional competence, meaningful activity, and enjoyment. These quality of life elements were translated into a variety of design decisions. “Autonomy,” for example, is expressed through the inclusion of lit memory boxes for display of photographs and mementoes outside resident rooms, affirming the unique history of each resident and assisting with wayfinding. “Meaningful activity” is realized through the location of residential scale therapy and activity kitchens in the neighborhoods for use by residents. “Dignity” is accomplished by the inclusion of private occupancy rooms with en-suite baths, as the design team firmly believed shared bathrooms compromise privacy.

There is perhaps a deeper, understated philosophy at work within the design of this scheme. It is a symbol showing honor for elders; a challenge to the wider Australian community to value older citizens by providing high standards of care and accommodation. For this reason alone, it should be viewed by Australians as exemplifying the culmination of good design and quality care provision.

Community and Belonging

How does the scheme design and operation support this ideal?

There are numerous case studies that point to a domestic style of architecture that serves to promote community and a sense of resident belonging. There is little that can be called “domestic” about the architectural design of the Montefiore scheme. Rather, it lies aesthetically somewhere between a contemporary hotel and a modern retirement complex. Wayfinding in the building is difficult, and even for a visitor with full cognition it is easy to lose your way. One would be forgiven for thinking that this, combined with 276 residents across five huge floors, is antithetical to the concept of belonging. Yet without a doubt, many of the residents feel they belong because, in the end, it is designed to be, or at least has become, so very Jewish. The Kosher kitchens, the elegant silver service, the Jewish symbols such as the mezuzah on bedroom doors, the celebrations of Jewish festivals, and the collaborations with Jewish schools and foundations all appeal to Sydney’s Jewish community, but also fully integrates that culture into the Home.

A “sense of home” is integral to creating an environment conducive to residents feeling like they belong. The Montefiore scheme has concentrated on expressing “home” through its interior design selections. Of all the included Australian case studies, this scheme has the most expensive finishes and furnishings. There is a sense of the “grand,” the color schemes are subtly modulated and the corridors have become galleries of original works by iconic Australian artists. In the entry foyer a large window valance suspended from the ceiling was painstakingly hand-covered with silver foil. The ceiling of the hydrotherapy center is pierced with fiber optic cables to give a very effective night sky effect. Timber woven into lattices is used extensively to screen off particular areas without closing them off. All of this reinforces and suggests the culture of honoring elders and the tremendous pride the community has in the Home.

To promote community, the design team attempted to break down the enormous scale and anonymity of the building using a neighborhood concept. Each neighborhood is made up of 15 single-occupancy resident rooms with a series of common areas located in the middle and at the corners of the building, connecting the neighborhoods. From the point of view of the built environment, the neighborhood concept is unconvincing: There is little to link the rooms other than their colocation in a corridor with themed signage and their convergence at the connecting common areas. However, the social program does much to make up for what the design fails to do to enhance the neighborhood concept. There is a separate social program for each neighborhood, guided by the interests and abilities of that particular resident group. There is even a friendly sense of competition between neighborhoods that serves to coalesce into a sense of community. The social program at the Home is strongly supported with 12 recreational activity officers on the floors, input from the Allied Health team and involvement of a very large volunteer group.

Innovation

If the operator pursues a policy of innovation and pursuit of excellence, how is this demonstrated?

The design approach underlying this scheme shows innovation. With such a large facility, the operator was determined that the design should have capacity for future flexibility. The design has communal spaces at its corners with residential blocks between. The residential blocks have been designed on a strict grid system that allows for three different types of modular residential suites. The “Classic Room” is a single grid width, the “Deluxe Room” one and a half, and the “Suite Room” two widths. This gives a range of accommodation sizes and standards infinitely flexible in combination. During the design phase, and even the construction phase, the operator was able to reorganize the mix of suites to develop the ideal combination for the incoming resident requirements. As the building is a framed structure with non-load-bearing walls, these modules can be revisited and revised in the future to respond to emerging needs and resident market demands. For example, though never included in the master plan, the Home has introduced a dental clinic to address the challenge many aged care providers experience in accessing appropriate and convenient dental care for their residents. The dental clinic initiative came through a partnership with an international fraternity of Jewish dentists, and the Home was quickly able to provide an adequate clinic by converting a deluxe suite into the dental clinic.

The Home’s design has also cleverly disguised the service areas. The scheme is actually made up of 16 separate buildings, each joined by narrow service links that can be accessed directly from the exterior. This reduces the presence of servicing activity in resident areas and, at least in a small way, promotes a more residential ambience.

The Home has also taken an innovative approach to the shared past of many of its residents. Australia is home to approximately 35,000 European survivors of the Holocaust, the largest number of survivors per capita of any country’s population outside of Israel. About one-third of the residents at Montefiore are Holocaust survivors and there are, in addition, those who make up the “second generation,” or children of survivors, who feel that the Holocaust is the single event that has had the most critical effect on their lives. Some suffer from post-traumatic stress disorder, a factor that can have a compounding effect in the management and onset of dementia. A training program has been initiated that is designed to equip staff with an understanding of the Holocaust, its impact on individual residents, and potential care issues that might ensue. Six hundred staff from the Home have visited Sydney’s Jewish museum to hear the Holocaust history directly from survivors. This training program assists staff in identifying possible triggers for distress and strategies to diffuse situations that may arise from these experiences of the residents. The architects were particularly aware of this history, and consciously tried to avoid materials or design decisions that would suggest feelings of imprisonment or institutionalization. The graceful, light-filled common rooms contribute considerably to negating these feelings.

Neighborhood Integration

Community Involvement

Is the scheme and service designed to integrate successfully with the local community?

Montefiore Home enjoys very strong support from Sydney’s Jewish community, which is strongly present in Sydney’s eastern suburbs. Nowhere is this more apparent than in the Volunteer Program, which boasts around 500 individuals of all ages devoting their time and resources to the Home. However, it is the colocation of services that really embed and anchor Montefiore in the community. During the early design stage of the building, a child care center, Moriah College Preschool, temporarily occupied land in a corner of the site. Since the opening of the Home, the benefits the preschool has brought have ensured that it became a permanent part of the master plan. The director of care services stated, “The preschool has provided so many wonderful opportunities for intergenerational interaction. We can’t see it going anytime soon.” A Sabbath program each Friday sees the children from the preschool visit the dementia-specific unit to light Sabbath day candles and join in a ritual blessing over bread and wine. Older children from the Moriah College Preschool participated in the Zikron V’Tikvah project, painting ceramic butterflies with residents in honor of the 1.5 million children who died in the Holocaust. Some of these preschool children have returned to the Home as volunteers. The Home saw this as a particularly important interaction as some residents are childless Holocaust survivors or have very small family networks. With the preschool, as well as other outreach programs, the Home has affirmed the value of older people within Sydney’s Jewish community.

An additional success of the Home is the onsite Burger Day Care Center. The Center operates programs for 180 frail, aged, dementia-specific and active healthy aging nonresidents each week. Operated in partnership with JewishCare, it provides opportunity for socialization for aged clients and respite for their caregivers. The colocation at the Home for this program provides a great synergy between community and residential care. There are occasional shared activities between Day Center clients and residents of the Home, which has increased the community’s familiarity with residential care at Montefiore. The Day Center clients access the Home’s Allied Health services and can make use of the Home’s hydrotherapy pool. This in turn provides a strong early intervention program in order to monitor client well-being and prevent crisis admissions to residential care.

Another aspect of community involvement was the design team’s approach to the local neighborhood consultation phase during the design phase and prior to construction. Extensive community consultations were held. Feedback from these meetings, such as increasing the setback from the perimeter by 15 meters (approximately 49 feet) to reduce its impact on the streetscape, was incorporated into the design. The future vision for the scheme is also very inclusive of the surrounding community. Stage two design will be centered around a public plaza, with cafés and retail outlets. Design architect John Flower views the plaza as both an interface for the residents and a gift to the neighboring community aimed at reinvigorating the local corner shops adjacent to the site and further anchoring the Home within the community.

Staff and Volunteers

Human Resources

Are policies and designs in place to attract good staff and volunteers?

Montefiore says it takes a multidisciplinary or universal staffing approach with on-the-floor staff, and particularly with those who work in the dementia-specific units. For example, recreational activity officers, whose primary role is to organize activities for residents, are also expected to assist with feeding at meal times. Conversely, assistants in nursing are involved in planning outings. This reduces the number of staff who interact with residents on a daily basis and helps to build a sense of community. The Home is also supported by a very large Allied Health team and assistants for therapeutic activities such as hydrotherapy and music, art, and dance therapy.

Montefiore has a union collective agreement with its staff, allowing the organization to attract staff through increased rates of pay and to adapt classifications that reflect a multidisciplinary approach.

The 500-strong volunteer program is supported by a dedicated volunteer coordinator. Volunteers have a mandatory orientation program and regular ongoing training. They are encouraged to debrief with onsite social workers if needed. A Volunteers Recognition Day is held annually to thank them for their contribution.

• Direct care hours per day per client: Nursing = 2.82, Other (Admin/Hotel and Food Services) = 2.15

Environmental Sustainability

Outdoor Living

Garden

Does the garden support principles of care?

The Montefiore scheme has a mixture of courtyards and open communal gardens. The dementia-specific units have direct access to the gardens, and there are separate courtyards for the assisted living and nursing home units. Some suites for assisted living residents open directly onto a winter courtyard. However, like many multistoried schemes, the conundrum here is that there is no access to gardens for residents on the fourth and fifth floors without taking an elevator to reach them. To some extent this is alleviated by communal areas at most corners of the building that let the outside in with floor-to-ceiling windows and, at some locations, being open to the floor above.

The design team describes the courtyards as barrier free, that is, they allow free and safe movement and optimize the functional ability of residents regardless of impairment. To this end, garden paths are wide and flat, rails and seating are ergonomically designed, garden bed walls double as seats or rest stops, there are few dead ends, and the design is simple and easy to understand. All these support the philosophy of autonomy, security, functional competence, and enjoyment. However, one of the awkward aspects of the design is the five-meter-high (approximately 16 feet) steel wall that separates the assisted and skilled nursing dementia unit gardens. In some respects it is a clever solution as it gives the nursing care unit, which is actually a story above the assisted living unit, access to a garden. However, residents of the assisted living unit are confronted by the overbearing wall. Although there is climbing planting that softens this wall, the height, combined with the four levels of building surrounding the courtyard, compromise the sense of freedom. The courtyards also offer little privacy from the overlooking stories and there is a sense as one walks through them that one is being spied upon from above. The planting selection and design are formal and even subtropical with appropriate plant materials, which, while making the garden beds vibrant, are more ornamental than inviting.

In the Australian context, the temperate weather and low population density has meant most older Australians have a strong affinity to “the backyard” as a relaxed garden space. The incorporation of the Home’s gardens really looks ahead to the next generation of older Australians, who have lived in higher-density housing with less access to the outdoors. The ultimate impact of this change is the loss of domesticity in outdoor areas. While other Australian schemes have defined their outdoor spaces as places of work with clothes lines and herb gardens, the Montefiore approach to the outside is more resort-like than utilitarian, for the use of residents as a place for relaxation, recreation, and contemplation.

1 Kane et al., “Quality of Life Measures for Nursing Home Residents,” Journal of the Gerontological Society of America, 2002.