Part A: Background – Resident Needs

Resident needs

This section gives background to help understand the needs of residents in robust SDA. It outlines the link between the built environment and resident outcomes. It then discusses the range of resident disability types, behaviours and environmental triggers that need to be considered in robust SDA.

Link between the built environment and resident outcomes

The research found a natural and important link between the built environment (building location, features and design) and resident outcomes. Outcomes include health, wellbeing, emotional control, behaviours of concern and forensic behaviours. Academic literature on the topic highlights the link between building design and residents’ physical, mental and psychosocial wellbeing (Mobley, Leigh & Malinin 2017; Wright, Zeeman & Whitty 2016; Zeeman, Wright & Hellyer 2016). Golembiewski (2015) noted that even minor changes or improvements to building design can create strong and long-lasting improvements in residents’ behaviours.

The impact of the design is massive … it can have a really positive effect on people and their behaviours, but if it’s inadequately designed it can have the reverse effect where people’s behaviours remain or get worse.

Stakeholders felt that robust SDA could improve resident outcomes by offering the unique environmental features needed for specific sensory needs and reduce environmental triggers. The literature found that good-practice design can reduce behaviours of concern. This reduces agitation, aggressive behaviours and the rate of self-injury (Bridge & Vasilakopoulou 2019; Sax Institute 2020).

Good design reduces the incidence of poor behaviour, behaviours of concern like self-harm, damage to property, injuring other people … as a result that improves the life of residents, their co-residents and the people that work with them.

Figure 1 shows the link between building design and resident outcomes.

Figure 1: Effects of robust SDA on resident outcomes

Stakeholders also said that effective robust SDA design could improve safety for SIL staff and other residents. It could deliver SIL support in line with residents’ support preferences. For example, it could offer:

• more ways for residents to increase their independence
• less obtrusive observation of residents by SIL staff
• reduced staff-to-resident ratios.

Range of people needing robust SDA

Stakeholders told us that robust SDA gave homes to a diverse group of people. These people have a broad range of sensory and environmental needs, disabilities and behaviours of concern (more so than other SDA categories). These included the following:

The people who are likely to be eligible for robust [housing] are also likely to have a sensory processing disorder … they might be over-sensitive or under-sensitive to particular sensory inputs.

• Disabilities. These included intellectual disability, autism, acquired brain injury, pica and Prader-Willi syndrome.
  • Some residents had co-occurring disabilities or impairments and co-morbidities (e.g. epilepsy, mental health disorders). These must be considered when designing homes.

You see a real mix of disabilities in this cohort … the people who are eligible for robust [SDA] often have a range of different diagnoses that are multiple and overlapping.

• Behaviours of concern. These included:
  • self-harming behaviours (e.g. banging one’s head against a wall)
  • aggressive or violent behaviours that may harm others (e.g. physical aggression or throwing furniture)
  • destructive behaviours that may cause property damage (e.g. throwing large pieces of furniture or breaking fixtures and fittings)
  • obsessive behaviours (e.g. ‘picking’ at loose carpet or floorboards)
  • improper sexualised behaviours
  • leaving the home without support (where residents need support to access the community)
  • constant hunger because of Prader-Willi syndrome.

To get into the robust category you generally have some pretty extreme behaviours of concern … the vast majority of those in robust will have these challenging behaviours.

The research found that residents had unique housing needs. These needs require tailored building design and fit-out solutions.

Environmental features that can trigger behaviours of concern

The research found a range of environmental features that could:

• trigger or increase behaviours of concern for residents
• lower quality of life and reduce resident outcomes.

These were specific to each resident. But stakeholders and the literature (Ahrentzen & Steele 2009; Bridge & Vasilakopoulou 2019; Tuckett, Marchant & Jones 2004) mentioned the following common environmental triggers:

• Sensory triggers. These are sensory features of the space that cause residents’ discomfort:
  • noise – loud sounds, noises made by non-verbal residents, high-frequency noises or noises given off by appliances such as refrigerators, lights and exhaust fans
  • light – glare, rooms that are too bright or too dim and flickering lights (e.g. dim lighting can have a negative effect on the mood of patients with dementia; glare and bright reflections can trigger visions; Bridge & Vasilakopoulou 2019)
  • strong smells – food smells, cleaning products or perfume/deodorant worn by staff.

When [my son] is escalated, the smell of food makes him sick and drives him nuts..

• Temperatures and humidity levels that do not suit residents’ personal preferences. The literature also suggests that poor airflow and lack of fresh air can agitate residents (Bridge & Vasilakopoulou 2019).
• Certain colours and textures trigger behaviours of concern for some residents.
• Under-stimulation. While too much in the environment (e.g. bright lights, loud noises) can trigger residents, stakeholders warned that under-stimulating spaces (those with limited sensory stimulation – e.g. without colour, artwork on walls or tactile stimulation) could also trigger residents’ behaviours of concern.

When you look at the cause of challenging behaviours, it often comes from a sensory need … for some people it’s touch, and you can’t use certain textures in the home. For other people it’s light or sound.

• Features triggering obsessive behaviours. Stakeholders said that certain features in the home could become items of fixation for some residents. This could lead to damage or pose risks to residents’ health and safety. These included:
  • easy access to electrical wire or circuit boards and exposed screws, which some residents would play with or unscrew
  • ‘pickable’ fixtures and products (e.g. floor coverings, plaster board and light switches). Stakeholders said that some residents would pick at these fixtures until they came loose. For example, they would pick until the carpet unravelled or large sections of paint/plaster came away from the wall.

There’s people with obsessive behaviours. They might obsessively eat, or pick at paint, or unscrew screws … if there’s something like light switches, they can flick or things they can get their fingers around to pick, they’ll go for it.

• Triggers related to other residents include:
  • behaviour that triggers unwanted responses – stakeholders said that behaviours of concern (e.g. screaming) could be a trigger for others in the home
  • SDA layout that offers little personal space – a lack of personal space or a sense of crowding by other residents can be triggering for some.

The triggers often come from the other people that someone is forced to share a space with. If you don’t have a place where you can get away from other people and the triggers to self-soothe, the behaviour will keep escalating.