As far as possible, the person whose home it is, should be able to influence the design of the bathroom. This means, where possible, they should be presented with choices of fixtures and fittings, equipment, walls and flooring. This is not always possible, especially if the bathroom is being funded by statutory services.


This white paper has been produced to assist occupational therapists to clinically reason decision making regarding bathroom-related adaptations. It covers:

  • Considerations when recommending a shower.
  • Supporting a person to access a bath.
  • Accessing a wash hand basin.
  • Hoisting within the bathroom environment.
  • The provision of a wash and dry toilet.
  • Heating the space in a bathroom.
  • Hazard considerations.

Changing places toilet with Closomat palma vita toilet

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Individual considerations: showering/bathing

Replacing a bath with a shower delivers more useable space within the bathroom, facilitating manoeuvrability of a person and any mobility equipment they may use, within the environment.

However, you must also consider the occupational impact of bath removal. Indeed, is bathing meaningful to the individual and if so, what solutions are available to support continued engagement?

As much as possible, consideration should be given to the location of the bathroom in a property. If appropriate and possible, a bathroom ensuite to or close to the bedroom allows ease of access in the morning or evening for washing and use of a toilet. This is particularly useful if a person is hoisted and requires a ceiling track hoist for bed and bath/shower transfers. Other considerations should include:

  • Whether the individual has tried a shower before and can tolerate the spray, or do they have any sensory issues that would exclude the use of a shower or require modifications to the shower or is a graded approach necessary?
  • Has the person tried a shower previously? Did this meet their needs?
  • Is the shower to be used independently or with support from a carer? Consider how the carer will stay dry.
  • What other equipment may be required, i.e., a changing bench or shower stretcher and allowance for the space for this. How the person transfers onto a stretcher and the height or height adjustability of this can be critical.
  • Mobile shower trollies may provide more flexibility with space and manoeuvring around the bathroom to access both sides when assisting with washing.
  • Users with limited mobility and/or sensitive skin may benefit from a body dryer. These may not always dry all parts of the body through (e.g., within folds of skin).
  • In the shower, what type of seating is required and an assessment should confirm if this should be wall-mounted, static or height-adjustable, or does the chair need to be mobile, i.e. a wheeled shower chair. Could a mobile chair fit over the toilet to reduce the number of transfers?
  • Consider the overall size and design of the shower area to facilitate independent use and to accommodate any further equipment or carers that may be required in the future. In some instances, where an existing bathroom is being altered, additional space may be acquired by the reconfiguration of door openings etc.
  • Half height screens may be necessary to keep the water within the shower area and allow access for carers; however, an open shower area or full height screens may be more aesthetically pleasing. Remember that an occupational therapist should support a person’s choices and aspirations and encourage a person to evaluate those choices.
  • If a person is going to access a shower area independently, consider how they will open shower doors or move screens. Some screens can be difficult to unclip or open and move out of the way and then replace once in the shower.
  • Shower curtains can be practical but again, can be challenging to open and close as they may have to be pulled over a long distance in order to be fully effective.
  • If a bathroom suite is to be replaced with a standard bath, consider the location of a bath for accessibility and when placed adjacent to a solid wall can assist with fitting grab rails.
  • Also consider the shape of the bath and how this may affect:
    – Ability to transfer.
    – Floor space within the bathroom.
    – The ease of fitting of equipment to the bath.
    – The shoulders or rim of the bath should ideally be 1.5 inches in width.
  • Often, a standard bath will not meet the needs of a person who has even a mild disability, due to the risks inherent in transferring over a bath side or attempting to get to the bottom of a bath. Therefore, following a robust assessment, the use of a specialist bath may be more suitable.
  • Height adjustable baths with the use of appropriate postural supports can provide the most appropriate to benefit from being immersed in warm water as well as washing. Often a person will require hoisting to access a height adjustable bath (see section on hoists below).
  • Should the washbasin be fixed, swing or be height-adjustable will depend on whether other members of the household will be using the room, and whether the disabled person is a wheelchair user.
  • Consider the person’s abilities when selecting a wash hand basin. Do they use a wheelchair? How far they can reach? Remember that some people use a wheelchair occasionally and therefore a height adjustable basin is essential.
  • Wall mounted wash hand basins offer more flexibility in regard to height and keeping the floor space clear. These can be set at the appropriate height for a person or fitted onto adjustable wall brackets to be raised in height, swung to the side or slid along to optimise access to other fixtures. If this is the case, then it is vital to ensure that there is a flexible supply and waste system. Although they are wall mounted, semi-pedestal basins can impede access for wheelchair users and should be carefully evaluated before installation.
  • Ensure the wall is strong enough to support the basin and someone weight- bearing on it: many users will use the basin in place of a support rail.
  • Careful consideration should be given to taps. Lever taps tend to be the most user friendly however there are other wash hand-basins on the market that offer infra-red operations for those individuals with limited dexterity.
  • Ensure that there is enough space around the basin; it may be that additional arm support is required which can be achieved through a worktop or specialist basin with extended sides. Remember that people may want space to store their soap, toothpaste and toothbrush in an accessible position.
  • Also consider where the hand towel will be located and if this is in an accessible place for a wheelchair user or ambulant person. Some wash basins have an integrated towel rail which reduces the reach required.


Hoists

It is important to consider if the provision of a ceiling track hoist is necessary for facilitating transfers onto a shower stretcher or into a bath. This may be connected to a hoist in an ensuite bedroom to reduce the number of transfers required.

  • Bathroom ceilings should be capable of supporting a ceiling track hoist. Under Building Regulations (Approved Document M) the ceiling specification should accommodate a hoist with a loading of 200kg. Ideally, at build stage, joists should be positioned to accommodate subsequent installation of a track hoist. In an adaptation, if the ceiling is not sufficiently strong, floor supports (gantry legs) and/or wall brackets may be required.
  • The hoist needs to enable manoeuvring of the user to points around the bathroom – over the toilet, into a bath, or to a shower stretcher.
  • The hoist system should enable transfer/moving of the user within the room and potentially into other spaces in the dwelling. This may include the need to transfer through doorways via a gated hoisting system.
  • A ceiling track hoist requires adequate clearance floor to ceiling to enable adequate lifting (minimum 2.4m).


Toilets (including wash and dry toilets)

  • The provision of a wash and dry toilet will require an electrical fuse spur adjacent to it to provide power to the unit.
  • Electrical safety is covered by Part P of the building regulations, which divides the bathroom into ‘zones’. A Closomat wash and dry toilet can be fitted into ‘Zone one’ of a bathroom although your local product specialist can give advice regarding the location of the toilet and proximity to a shower.
  • Consider how the user will transfer onto the toilet, whether they need space adjacent to the toilet for a side transfer or turning space to manoeuvre a wheelchair into an optimal position for transferring.
  • It is always helpful to consider future needs when designing a bathroom, for example, will a person’s condition deteriorate to a level which requires the use of a shower/toilet chair. The height of the toilet should be considered if a shower chair needs to be pushed over it.
  • If the person stands to transfer, how will they do this? Consider equipment that may be required adjacent to the toilet and again, what equipment may be required in the future if their needs change.


What are Wash and Dry toilets?

Wash and Dry Toilets were invented by Closomat over 60 years ago to provide solutions for people having difficulties with toileting and, in particular, with cleaning themselves afterwards.

Put simply, Wash and Dry toilets (sometimes referred to as “shower toilets”) combine the functions of a toilet, a bidet and a drier in one easy to use unit. The toilet flushes, washes the user with warm water, and finally dries with warm air.

Wiping with toilet tissue requires manual, mental and physical dexterity, flexibility, and balance. The nature of certain disabilities or medical conditions means that some people are not able to wipe themselves, which can result in personal hygiene issues, higher risk of infection and an increased burden on family members or carers. This can, in turn, lead to psychological issues, feelings of isolation or reduced self worth from the loss of independence and dignity.

Whether the user is disabled or not, inevitably one is cleaned better with water than with toilet tissue. Furthermore, with hand/body contact removed the risk of infection or cross-contamination through failure to wash hands is greatly reduced.

Clearly, the fundamental reason for Wash and Dry toilets is to effectively wash the anal area, but the additional personal and psychological benefits cannot be under-stated.

Therefore, specifying a Wash and Dry toilet can have a fundamental, life-changing impact on a person’s life.

For more information on Wash and Dry toilets – please click here

Heating

Some people have medical conditions that cause them to struggle to regulate their body temperature or have sensory issues causing them to not feel heat or cold. An understanding of a person’s condition is important when planning to heat a room.

  • The method of heating a bathroom should be carefully considered as there are implications for safety and space. A wall mounted fan heater only provides a small amount of heat and could be expensive to run.
  • Under floor heating increases the amount of usable space within a bathroom and can ensure an even distribution of heat as well as drying the floor more quickly. It can be damaged if wall mounted grab rails and other equipment that requires floor fixing is necessary.
  • Electric or mains operated towel rails are common; however, they should not be used to assist with transfers and consideration should be given to their location to avoid this.
  • If the risk of falls is high or if there are challenging behavioural issues, a low surface temperature radiator is a safer option as the outer casing does not exceed 43 degrees Celsius.
  • Wall mounted, electric fan heaters will likely only warm a small amount of space or a smaller room but can be useful as it does not require the entire central heating system on to warm one room.

Hazards

  • Floor coverings should have a low slip rating and have no glare and strong tonal contrast with the room adjacent to the bathroom should be avoided for people with dementia (they can perceive changes as a step and this increases risk of falls).
  • Consider how someone will summon assistance in an emergency if they are using the bathroom alone.
  • Storage is important, as items such as continence pads stored on the floor can cause a trip hazard and minimise turning space.
  • It can sometimes affect the stability of rails and other equipment if the walls in a bathroom are not solid. Further advice should be sort from an appropriately qualified person to establish if the wall structure will cause any issues when fitting equipment.

Important considerations in design

  • Door widths and turning spaces are important aspects of accessibility in a bathroom. Remember that building regulations recommendations may not meet an individual’s needs and an assessment is required. Turning circles do not just apply to wheelchairs; walking aids, transfer methods, presence of a carer, gait and being plus sized all influence how much space is required in a bathroom.
  • As far as possible, the person whose home it is, should be able to influence the design of the bathroom. This means, where possible, they should be presented with choices of fixtures and fittings, equipment, walls and flooring. This is not always possible, especially if the bathroom is being funded by statutory services.
  • Consider the impact of lighting. Task lighting may be more appropriate as it highlights specific spaces of function and halving the distance from light to object increases visual acuity threefold.
  • Colour contrast: Correct colour contrast is crucial in enhancing accessibility anywhere in the home but nowhere more-so than the bathroom. In particular using 2 colours or shades where the LRV difference is greater than 30 will create the most noticeable contrast between an object and its surroundings. Furthermore, colour contrast is best achieved with contrasting shades of the same colour rather than different colours. When considering this in relation to domestic design it also supports a more homely environment rather than the clinical look you might expect.
  • However, as occupational therapists we should appreciate the importance of items in the home being more than just the function they perform. Improved desirability can influence frequency of use and allow disabled people to feel more equal with their non-disabled peers.
  • Occupational therapists should understand a person as an individual, occupational being and take time to understand their unique life story. This should be reflected, as far as possible in the design.
To download this white paper – please click here