Would You Want to Live in a Hotel?

I like a nice hotel. Most people do. Somebody else makes the bed, the coffee comes on a tray, and for two nights it is a genuine treat.

By the third morning I want my own bed.

Not because anything is wrong with the hotel. Because a hotel is designed to impress a person who is passing through, and I am not passing through any more. There is nowhere for my things. The drawers are empty and I will not remember which one I used. The light switch by the bed turns off a lamp on the other side of the room. The temperature is set by a system somebody else controls. Everything is lovely and none of it is mine.

I have ADHD, so I feel that faster and harder than most people do. But I do not think I am unusual in it. I think almost everybody, given a month, would trade the marble for a shelf they could put things on and actually see.

Which brings me to a question I have started asking care home managers, and I ask it genuinely rather than as a gotcha.

Would you want to live in a hotel?

First, the good news, and I mean this

Care home buildings have got enormously better. I am old enough in this sector to remember homes with four to a room, a bath list, one television turned up too loud and a smell in the corridor you could not do anything about.

What has replaced them is a genuine achievement. Ensuite rooms. Proper natural light. A cinema, a hairdresser, a café. Gardens people can actually walk in rather than look at. Food that arrives on a plate somebody has thought about. Providers have spent real money doing this, and they were right to.

So none of what follows is nostalgia for the old buildings, and it is not a complaint about anybody's carpet. Beautiful is not the problem. Beautiful is lovely, and residents notice it and are proud of where they live.

The question is only ever what happens when beautiful and usable pull in opposite directions, and which one wins.

The show round is sold to the wrong person

Here is the structural reason this is hard, and it is nobody's fault.

The person who chooses the home is almost never the person who lives in it. It is a daughter, usually, in her fifties or sixties, carrying an amount of guilt she cannot put down. She has forty-five minutes, she is looking at three homes this week, and she is trying to work out whether she is doing a terrible thing.

What reassures that woman is a chandelier in the entrance, a bistro, and a lounge that looks like somewhere she would happily sit. She is trying to buy back some dignity for her mother, and the building is the only evidence she has.

So homes get built and decorated for that forty-five minutes, because that forty-five minutes is what fills beds. It is a rational response to a real commercial pressure.

The trouble is that her mother is not going to spend forty-five minutes there. She is going to live there, on average for something like three years, and she is going to spend that time looking at the place with a completely different pair of eyes.

What those eyes actually see

This is where it stops being a matter of taste and starts being evidence, because dementia design has been studied properly for decades and the findings are not vague.

The Dementia Services Development Centre at the University of Stirling recommends a difference of at least 30 points of Light Reflectance Value between critical surfaces. Floor to wall. Door to wall. Handrail to wall. That is a measurable number, and it exists because ageing eyes and a dementia-affected visual system lose the ability to pick an edge out of a low contrast scene.

Now think about what has been fashionable in interiors for the last decade. Tonal schemes. Everything within two shades of everything else. Soft greige walls, soft greige floor, soft greige doors, all beautifully coordinated.

That is not a mistake anybody made carelessly. It is the current definition of tasteful, and a designer who delivered high contrast would have been told it looked municipal. But to a resident it can mean the wall, the floor and the door are one continuous surface, and there is no doorway.

A few more, all of them things I have watched happen:

• Shiny floors. A polished or high gloss finish reflects light and can read as wet. People stop at the edge of it, or shuffle, or take somebody's arm they did not need to take. It looks immaculate and it makes a corridor feel unsafe.
• The join between two floors. Homes rightly do not use rugs or loose mats, because they are a trip hazard. But every building still has the point where the corridor carpet meets the vinyl in a bathroom, or where one zone changes to another, and a dark threshold strip or a sharp change in tone can read as a step or a hole. People stop dead at it, or step over nothing, or refuse to cross. Stirling's guidance is that adjoining floor finishes should be tonally close, which is the opposite of the usual design instinct to define a zone with a contrasting border.
• Bold patterned carpet. A strong geometric or floral can look like movement, or like objects on the floor. I have seen a resident bend down repeatedly to pick up flowers that were woven into the pile.
• The white bathroom. White toilet, white floor, white walls, white grab rail. There is nothing there to find. A coloured toilet seat and a contrasting rail cost very little and are among the most effective changes a home can make.
• Mood lighting. Low, warm, atmospheric lighting photographs beautifully and is exactly wrong. Older eyes need considerably more light than younger ones to see the same thing. A lounge that looks inviting in a brochure can be a room where nobody can read a newspaper at four o'clock in November.
• Hard surfaces. Glass, stone and polished concrete look expensive and turn a dining room into an echo chamber. For anybody with sensory processing differences, and for anybody with a hearing aid, that noise is not background. It is the whole experience.
• Mirrors. Popular in entrance halls and lifts, and genuinely distressing for a person who no longer recognises the older face looking back.

None of that is a design failure by an incompetent person. Nearly all of it is a design success, judged by the wrong criteria.

The wallpaper

I suggested to a home once that they needed more signage. Bigger, clearer, lower down, with words and a picture, so that people could find the toilet and find their own room.

The answer I got was that they did not want to spoil the wallpaper.

I want to be fair about that answer, because it is easy to quote it and make somebody look foolish. They had just spent a great deal of money on a refurbishment. They were proud of it. The wallpaper was genuinely lovely. And most dementia signage, let us be honest, is horrible. It is A4, laminated, in a font from 1998, stuck up with Blu Tack at the wrong height. If somebody has just spent forty thousand pounds on a corridor, of course they do not want that on it.

The mistake is not caring about the wallpaper. The mistake is thinking those are the only two options.

Signage can be designed. It can be brass, or ceramic, or vinyl cut into the same palette as the scheme. Guidance generally puts it lower than people expect, around 1.2 to 1.4 metres, because a person with dementia tends to walk looking down rather than ahead. A sign at standard height is a sign nobody sees.

The same goes for bedroom doors. A memory box or a personalised sign beside somebody's door helps them find their own room, and it does not have to look like a school corridor. It can be joinery. It can be a proper frame. Some of the best I have seen were built into the wall at the design stage and look like part of the building, because they were.

You can have the wallpaper and the signage. It costs a conversation with the designer at the right moment, which is early.

What a home actually needs to feel like

Ask people what makes somewhere home and almost nobody says the decor.

They say being able to find things. Having a place where your own belongings live, where you can see them. Being able to make a cup of tea, or at least to be near somebody making one. Being warm enough, and being able to do something about it if you are not. Knowing where the door goes. Being able to shut it.

I wrote a while ago about why I live in what looks like a museum of everything I have ever owned. If I put something away it stops existing, so I keep it out where I can see it. In my own home that is my system. In a beautifully styled room where clutter would spoil the look, it is a problem to be managed.

That is the whole tension in one sentence. A hotel room is at its best when it is empty. A home is at its best when it is full of somebody.

A resident's room that has been styled to match the corridor is a room somebody is visiting. A resident's room with too many photographs, an ugly chair they refuse to give up, a bag of wool and a biscuit tin with something else in it is a room somebody lives in. The second one will never appear in the brochure, and it is the one that is working.

Should I choose the luxury care home or the smaller, homely one?

This is the question I get asked most, usually by somebody who has been round both in the same week and come out more confused than they went in.

The honest answer is that the question is the wrong shape. Neither the size nor the decor predicts whether somebody will have a good life there. I have seen excellent care in a converted Victorian house with a tired carpet, and excellent care in a purpose built home with a cinema. I have seen the opposite of both.

But there are real differences, and they are worth naming rather than pretending away.

What a larger, well funded home genuinely gives you. Facilities a small home cannot afford to run. A cinema room, a café, a hairdresser on site, a garden with proper paths, sometimes a physiotherapist or a dedicated dementia lead. Ensuite rooms as standard. A newer building designed to current standards, with wider corridors and better natural light. If somebody is sociable and wants things going on, that is not a frill. That is their day.

What a smaller home genuinely gives you. Fewer people, so less noise and less coming and going. Staff who know every resident rather than every resident on their floor. More consistency, and often less reliance on agency. Somebody who has never enjoyed a room full of people may be far happier in a home with eighteen residents than in one with ninety, whatever the ninety looks like.

A word about the premium. A luxury home charges considerably more than the local average, and some of that difference is the building. So ask what the extra actually funds. If the answer is staffing ratios, specialist training and a dementia lead, that is worth paying for. If the answer is largely the entrance hall, then you are buying reassurance for yourself rather than a better Tuesday for your mother. Both are understandable purchases. It is just worth knowing which one you are making.

And then there is the thing neither brochure will tell you, which is what actually predicts a good life in a care home. Roughly in this order:

• Staff turnover. Ask for the figure. A home that cannot keep staff cannot know its residents, and knowing residents is the entire job. This one question will tell you more than the tour did.
• How much agency they use, and whether it is at least the same agency people each time.
• How long the manager has been there. A home that has had three managers in two years is a home in trouble, however new the carpet is.
• The CQC report, read properly. Not the headline rating on the front. Read the actual wording under caring and under responsive, which is where the difference between a pleasant building and a good life tends to show up.
• Whether anything you say travels. Tell one member of staff one specific thing about your mother. Come back a week later and see whether anybody else knows it. That is the closest thing to a reliable test I have found, and it costs nothing.

A home that answers those well and has a slightly dated carpet is a better home than the reverse.

Things to look at, whichever side of this you are on

If you run a home:

• Walk your main corridor at the eye height of somebody sitting in a wheelchair, and then again looking at the floor two metres ahead, which is where a lot of people with dementia are actually looking.
• Turn the lights on at four o'clock on a dark afternoon and sit in the lounge for ten minutes. Could you read a letter?
• Stand in a bathroom and ask whether you could find the toilet if you could not pick a white shape out of a white background.
• Walk every point where one floor finish meets another and ask whether it reads as a threshold or as a hole.
• Count how many residents can find their own bedroom without help, and how many need to be walked back.
• The King's Fund tool Is your care home dementia friendly? is free, it is a proper structured audit across seven areas, and it is now maintained by the Association for Dementia Studies at the University of Worcester. It takes an afternoon and it will tell you more than this article can.

If you are choosing a home for somebody:

• Ask to visit twice, and make the second visit mid afternoon on a weekday rather than a Sunday morning. That is when a building shows you what it is like.
• Look past the entrance hall. The entrance hall is the shop window. Look at a corridor on the top floor.
• Ask whether residents can bring their own furniture, and how much. Then look at whether anybody actually has.
• Look at the bedroom doors. Can you tell one from another? Could your mother?
• Ask what they would do if she reacted to the laundry products, either on her skin or because she could not stand the smell. A home laundry runs one detergent at temperature for infection control, so the answer will not be that they use hers. A good answer is that personal items can go home with the family, and that somebody would actually notice.
• Ask which is the noisiest hour of the day, and what they do about it. You will not be shown round at a mealtime, and you should not be, because mealtimes are protected. So ask instead.

None of that photographs well. All of it matters more than what does.

So, would you?

I do not think anybody sets out to build a hotel for people who are not going anywhere. I think it happens because the person paying, the person visiting and the person deciding are all well, mobile, and staying for an hour.

The fix is not to make care homes plainer. It is to hold two things at once. Make it beautiful, and then check it against the eyes of somebody who is going to live in it for around three years on average, and who cannot tell you what is wrong.

The best homes I have worked in did both, and it did not cost them their aesthetic. It cost them one conversation, early, with somebody who knew what to ask.

If you want to work out what a particular person needs from a room rather than what people with dementia need in general, that is what the Personhood Profile is for, and it is free. There is a whole section on senses and one on what somebody would want around them. The sensory guide goes through a building room by room in the same way.

And if you have ever stood in a beautiful corridor and not been able to work out which door was yours, you already understand the whole argument.