Complex Adaptations

In general, houses are not designed with disabled users in mind. Getting through the front door over a high threshold can be almost impossible and narrow corridors, circulation spaces and doorways are always a problem. The two most important rooms in terms of utility – the kitchen and bathroom – are often difficult to use.

Improving accessibility requires a return to first principles; to look at how the available space can be best arranged and utilised to give the best value for money solution. Planning and Building Regulations always have to be observed and finance can be restrictive.

This guide aims to improve the provision of larger adaptations by:

• setting out the process;
• placing the client at the centre of the design process;
• promoting joint working;
• balancing the needs and expectations of the client with value for the public purse; and
• understanding the space and design principles underpinning major adaptations.

This section is divided into 7 parts that complement each other to create the completed job.

For the purpose of this section we will focus on schemes funded by the Disabled Facilities Grant although much of the information will apply more widely.

Choice in the design of Adaptations

Adaptations funded by a Disabled Facilities Grant (DFG) are designed to meet an ‘assessed need’. The final design of the adaptation, particularly in complex cases where more than one building element is required, may not be what the client aspires to, and may even be something they dislike. Should the client have to accept something they do not like being done to their home and what is the role of choice in the design of state funded adaptations?

The Care Act 2014 changed the emphasis on how Local Authorities should perceive the ‘needs’ of the individual. Section 1 of the Act says that the social care authority has a general duty to promote the wellbeing of the individual, including personal dignity, physical and mental health and emotional wellbeing, control over day to day life, and suitability of living accommodation.

In all there are nine components to the definition of ‘well-being’ and to qualify for support the individual must fulfil a minimum of two. This doesn’t mean that a person can have whatever they want, but due regard must be given to their views, wishes and feelings.

In contrast, the DFG provided under the Housing Grants (Construction & Regeneration) Act 1996 is far more prosaic considering what is ‘necessary and appropriate’ against what is ‘reasonable and practicable’. A far more limited scope and one that typically provides little choice for the client whilst providing ‘best value’ (usually the cheapest option) for the public purse.

In the case of an adapted bathroom this will normally mean the provision of plain white tiling, entry level waterproof, non-slip flooring, and half-height shower screens. This can give a very ‘clinical’ feel to what is a family bathroom. The result may be that the client does not feel happy using the new bathroom as it simply confirms their increasing frailty; or is reluctant to invite friends and family into the home and therefore becomes increasingly isolated.

In the case of an adaptation for a child or perhaps an adult with a long-term spinal injury it might mean trying to meet the greatly increased care needs of the individual within the existing footprint of the house due to the maximum value of the DFG (currently £30,000). This can often lead to a compromise in terms of available space. Ironically, it is often the creation of additional space that is the critical factor in the success of any such adaptation. In this case the result is all too often that the family and carers continue to struggle to help the client effectively, the client is unable to navigate the home independently, and the extensive equipment that is designed to help their lives simply becomes a burden and impossible to store safely.

So, the choices engendered by the Care Act can be frustrated by the ‘needs’ of the Disabled Facilities Grant assessment. There is plenty of guidance published on how to deliver a successful adaptations service that meets the reasonable expectations of the client, including discretion provided by the Regulatory Reform Order 2002. On the other hand, sadly, there are plenty of Local Government Ombudsman judgements that demonstrate where this not happened.

Placing the DFG funds within the Better Care Fund was intended to lead to a better integrated, ‘person-centred’ system. The key to success lies in the quality of the assessment of the individual client that balances their reasonable needs and wants against the benefit to the public purse of providing support (in this case the adaptation).

A successful adaptation, i.e. one that is used, may reduce or defer other costs within the care system and therefore it is essential that the client is heard. It may not only be funded through the provision of a DFG, but by other public funds. All cases should be reviewed after an adaptation has been carried out to ensure that any care costs are reduced as a result of having the adaptation installed. It is also important that the effect on carers is recorded as evidence shows that installation of adaptations can considerably lighten their load, reducing long term stress and keeping the family unit viable for longer periods.

Of course, there are other options available to clients who aspire to an adaptation beyond which the local authority will fund. To accommodate this, many authorities offer what is commonly known as ‘Preferred Schemes’ by which a client can receive the notional amount for an adaptation and then pay any additional amount themselves. This is a creative solution that satisfies the Council’s need to manage their budget but also allows the client to achieve a higher cost adaptation that suits their aspirations. This is only an option if the client or family are able to fund the additional amount. In fact, the Housing Grant (Construction and Regeneration) Act 1996 recognises this compromise in clause 23(3).

Preferred Schemes in practice

Sometimes a client may wish to have a scheme designed which goes over and above what the Local Authority deems strictly necessary. In these circumstances the local authority would follow the following procedure:

1. Assess which adaptations are “necessary and appropriate” and estimate the cost of those adaptations based on an approved schedule of rates or prices for similar schemes the council has approved in the past.
2. Using the estimated cost and the client’s assessed contribution, the authority would notify the client of the amount of grant they could receive and any required features of the Preferred Scheme.
3. The client will often need to appoint a Home Improvement Agency or their own architect to design the Preferred Scheme including the required features. The grant may include part of the fees involved in designing the Preferred Scheme.
4. The client will need to seek the approval that the Preferred Scheme is acceptable, preferably before being submitted for planning and building control approval, and a detailed specification is prepared for pricing purposes.
5. The approved drawings and specification should be sent to a minimum of two contractors for pricing.
6. Once the application is submitted the grant will be calculated taking into account any assessed contribution and an approval notification issued.
7. Once the approval is received by the Preferred Scheme may commence on site.

The design assessment stage of the adaptation process is one of the most critical aspects and it is important to gather the correct information. The discussions that take place with the client at this stage can determine whether the adaptation will be a success or failure.

Each client will be different with varying requirements and ensuring that these are correctly identified will be critical to the success of the project. The information that you receive will allow you to create a bespoke proposal for that client rather than a ‘one size fits all’ approach.

When should you contact a client? Many clients will have a preferred time of day to be contacted. This might coincide with their waking times or when care tasks are not being performed. Understanding a client’s routine is essential not only for planning their adaptation works but ensuring you are delivering a positive client experience.

Who is your client? A client is likely to have other professionals involved with the adaptation, including a care team, case manager, relative, solicitor or financial deputy. It is critical that you understand who has authority to make decisions (particularly those with financial implications), who the client is for the purposes of the contract and who you can discuss the case with.

Is it safe for your client to use certain equipment? In terms of the adaptations, the physical characteristics of the client are incredibly important. Whilst many may shy away from asking the difficult questions, knowing the client’s height and weight is very important to ensure the correct equipment is specified. Knowing the physical characteristics of the client will also ensure that any hoisting arrangements are fit for purpose and will not cause any health and safety concerns for carers.

If the information is not provided by the Occupational Therapist, you could consider testing the client’s reach. This helps to determine the level equipment should be placed at and is very important when considering the functionality of kitchens, bathrooms and utility spaces.

 

Level of Mobility

The reason the adaptation is being proposed is likely to be because the client has reduced mobility or another impairment that might place them at risk in the home. It is essential to determine whether the client’s perception of their mobility level actually matches reality.

There are some clients who do not want to admit they are having problems and might try and hide the extent of the condition. However, others might innocently not realise they can actually do more than perhaps they realise. In both cases, it is important to ensure the occupational therapy report is carefully considered against the client you actually meet during the visit. This will then allow you to identify any discrepancies, which are better dealt with at this early stage.

There are many different ways of classifying a client’s level of mobility but many will consider the following:

• Are they ambulant either with the assistance of a carer or a support aid?
• What walking aid do they have (e.g. walking stick, walking frame, wheeled frame)?
• Is the client reliant on a wheelchair?
• Is the wheelchair powered or manual?
• Is the wheelchair required indoor, outdoors or both?
• Does the client require hoisting?

The assessment should not only consider the level of mobility but also how long this can be maintained by the client. A client might be able to mobilise but for only relatively short distances and it is important to understand these limitations so that you don’t place the client at risk. Some of the questions you might like to consider are:

• Can the client climb and descend stairs?
• Does the client need any support when climbing or descending stairs (e.g. rails, bars etc.)?
• How long can the client mobilise for before feeling tired?
• Does the client require the assistance of a carer or other person to help them mobilise?
• Is the client’s level of mobility likely to change in the future?

The questions considered above directly relate to physical mobility but other factors will impact on mobility. For instance, does your client have any other conditions (e.g. being colour blind, hearing loss, partial or full sight loss, epilepsy etc) that might influence the overall decisions that are being made (e.g. a stairlift might not be appropriate for someone who is likely to experience seizures on the stairs)?

Family

The property to be adapted for the client may not just be a home for the client but also for the rest of the family. The adaptation proposal needs to consider all occupants’ needs for it to be truly successful. A good example is provided by a simple bathroom to wet room proposal.

The obvious solution for many clients is to remove the bath and replace it with a level access shower. This provides an excellent solution for many clients but may present issues where other family members enjoy bathing or have children. The loss of a bath can become a very contentious issue. Understanding these needs can allow the designer to input these requirements into the design or to manage the client’s expectations by explaining why it is not possible.

At the client interview stage, it is worth noting other members of the household and if they have any special requirements. This will also include pets who are often the number one consideration for many clients!

Personal Hygiene

The daily functions are one of the most critical for a successful adaptation. The ability for the client to use the bathroom safely is essential. At the heart of the adaptation should be the central thread of making the client’s daily life easier.

When discussing with the client it is important to establish whether they can toilet independently, need assistance or make use of aids. Many clients might feel uncomfortable talking about this subject as it can be perceived as undignified. However, many toileting solutions (e.g. wash dry toilets) can often help the client regain control and turn it into a better experience.

Bathing and showering is another area of personal preference. Many adaptation designs provide for a bath to be removed and replaced with a level access shower. However, this overlooks the therapeutic effects of a bath and possibly a client’s preference. Understanding how your client bathes currently and their future aspirations is critical. This does not mean the client will get exactly what they want (perhaps due to limited budgets) but at least their expectations can be managed.

Personal hygiene questions will not only affect the design of the bathroom but will also impact on utility facilities and the juxtaposition of rooms in the property. A client who suffers from periods of incontinence might produce extra washing and there might be a need for a sluice room. The positioning of the toilet facilities will also be important to ensure the client is close to accessible facilities.

The Kitchen – Cooking and Eating

One of the key questions during the design process is to understand the client’s daily routine and what activities/roles they undertake. An essential part of any household is the preparation and eating of meals.

The kitchen is a high-risk area and the designer’s role is to ensure these risks are minimised whilst allowing the client to function in the kitchen environment. Central to this is getting an understanding from the client about what activities they would like to perform in the kitchen. Some clients may simply want to prepare a drink and a light snack, so extensive kitchen adaptations would be inappropriate. However, others might like to cook full meals so a fully accessible kitchen would be critical. Only asking the client about their aspirations will identify their individual requirements.

Preparation of meals, drinks and snacks can present significant design challenges. There are plenty of innovative solutions to facilitate safer use of the kitchen. These include rise and fall counters, accessible cupboards, slide and hide ovens, accessible appliances and adapted utensils.

Many families see a communal eating area as central to the home. The dinner table is often the hub of family life and making this accessible to the client can be critical. This might be simply considering circulation space around the table or might require the provision of a height-adjustable table. These simple changes can have a huge impact on family life.

Sleeping Arrangements

Understanding a client’s sleeping arrangements is very important for a successful design. The designer will need to be aware of their specific requirements, including:

• What type of bed does the client have (e.g. single, double, king etc)?
• Does the client have a special bed (e.g. hospital profiling)?
• What are the dimensions of the bed?
• Will the client be sharing a room with another person?
• Does the client have any special considerations when they are asleep (e.g. close to a toilet, require oxygen, need a quiet environment, close to a carer etc.)?

All the items above will help the designer formulate a better picture of the client’s sleeping routine and requirements.

Household Duties

Each client will have varying degrees of involvement with household duties. The designer will need to understand whether the client need access to places like utilities, laundry appliances or cleaning cupboards. Only by understanding the individual requirements will the designer ensure money is not wasted on unnecessary adaptations.

Carers

The care regime for clients is a fundamental part of their daily routine. A day carer might not require any facilities but a ‘live-in carer’ will almost certainly need to be considered as part of the housing design.

The design assessment is a good opportunity to get a better picture of how the care team interact with the client. One of the key pieces of information is to establish how many carers the client has, how long they spend with the client and whether there are other privacy issues to consider.

From a design perspective, it is important to establish whether the client has or might need to have in the future a live-in carer. The client will find it easier to attract a good carer if they are able to offer good facilities to a live-in carer.

The rest of the family’s views are also important when designing for live-in carers. Many families want to try and maintain a level of privacy. This means that it is essential to consider whether a degree of separation between the carers and the rest of the family can be maintained. This might be by providing a separate entrance to the property or clustering of certain rooms together. Each case will be different and largely depends on the composition of the family (e.g. a single person requiring care is unlikely to need these additional considerations).

Mobility Equipment

Clients are likely to own, use and need to operate a wide variety of mobility aids and equipment. This presents two problems for the designer: the first is extra storage and the second is space to adequately use this equipment.

• The designer should consider obtaining:
• The dimensions of any mobility equipment being used to include a turning circle (if appropriate).
• A list of all the equipment that is used or might be used in the future.
• Where in the house is the equipment used?
• Does the equipment require charging when not in use (this can affect power supply points)?
• Will the equipment require cleaning after use?

A successful adaptation will provide solutions that allow the mobility equipment and aids to be at hand when required but good storage when not in use. Another good source of information about mobility equipment is from the supplier who might be able to provide details about space requirements, storage, cleaning and maintenance.

Hobbies and Physiotherapy

When carrying out adaptation designs, it is very easy to focus on the immediate critical requirements of the client like access to the kitchen and bathrooms. However, many clients have interests or hobbies that may also influence design decisions. These hobbies may simply be for enjoyment but can also offer other physical benefits that might assist the client’s condition in the long term (an obvious example would be an activity like swimming).

Many clients will also have the need for daily or weekly physiotherapy sessions. These might be conducted away from the home at local facilities but often many client will have a programme that needs to be completed at home. Asking the client about the physiotherapy/rehabilitation requirements is very important to ensure adequate provision is made for the equipment. Again, the physiotherapist should be able to provide a list of equipment and indicate what space is required to use it safely. However, the suppliers of such equipment will be able to provide space standard guidance in relation to circulation space around gym/physio equipment.

Vehicles and Travel

Access to the house, particularly from a vehicle is very important. In many houses, this often presents an issue because driveways are too small or may not have off-street parking. There are some important aspects to consider as part of the design and to discuss with the client:

• What car or vehicle does the client have?
• How does the client transfer to and from the vehicle (e.g. side, rear, front)?
• Will the client be a driver and/or passenger in the vehicle?
• Are there any parking restrictions in the vicinity or shared facilities?
• How long does the transfer usually take?
• What is the primary entrance for the client?

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