Using functional rooms – including the bathroom/going to the toilet – is the second biggest problem faced by families with a severely disabled child (Joseph Rowntree Foundation 2008). One in five adults aged 65-69 need help with one or more activities of daily living (such as using the toilet unaided). By the time people reach their 80s, this figure rises to more than half (Independent Living, 2020).
Some 1.8 million people need accessible housing and 1 in 6 people do not have the accessibility features they require (Provan, Burchardt and Suh, 2016).
Only 7% of homes in England meet current minimum accessibility features (Equality and Human Rights Commission, 2018). Under current regulations, homes need only be ‘visitable’ i.e. level access, flush threshold, toilet on entrance level, door width compliant with Document M; accessible, adaptable, wheelchair-accessible are all optional requirements.
There is growing pressure for an accessible housing default to be included under National Housing Policy.
25% of households of a person with a disability need a home adaptation.
Statistics show that:
- Bathrooms are the most common form of home adaptation, with 20% of people with a disability in private households using them.
- Some 500,000 households with no adaptations say they needed either a special toilet seat or other aid to use the toilet.
- A further 200,000+ that already had some adaptations specified provision of an additional toilet, relocation of an existing WC or aids to use a toilet as a requirement they now deemed necessary (English Housing Survey 2016).
Yet only 7% of properties meet the four key features of visitability/accessibility – level access, flush threshold, wide doors and circulation areas and use of a toilet on the ground or entry floor (English Housing Survey Homes Report 2016).
New build – Lifetime Homes/Part M (4) Category 2
Under the Lifetime Homes/ Category 14 criteria, bathrooms should be accessible.
In dwellings of more than one storey, there should at least be an accessible toilet on the entry level, with the flush on the cistern side furthest away from the wall.
The toilet should have a clear space in front of 750mm to enable oblique or frontal transfer and walls should be strong enough to support adaptations such as grab rails.
Lifetime homes should also deliver potential to future-fit a hoist to provide a transfer route from bedroom to bathroom, by which ceilings should be strong enough to support the hoist with a 200kg weight loading.
Regulations do not specify a minimum ceiling height in domestic environments, however, experience shows that to enable adequate lifting a minimum 2.4m floor to ceiling is an appropriate dimension.
It is good practice that the main bedroom and bathroom are adjacent, with a connecting, full height panel that may be knocked out to form a direct doorway or link of at least 900mm width.
BS9266 recommends a level access shower be provided somewhere within the home from the outset; if not, space and drainage provision should be made within an accessible bathroom to simplify future retrofitting.
We can often become fixated with the physical environment and neglect other aspects that contribute to making a bathroom inclusive. Indeed, many ‘wheelchair-accessible’ spaces may not be accessible for people with other disabilities or needs.
There are a number of design principles that should be considered when adapting a bathroom. These include:
- Where the bathroom is located in the dwelling, for example if it is upstairs, how will it be accessed in the long-term.
- What type of mobility aid is used and will this be likely to change over time.
- The space required to accommodate for the current and any future mobility aids (for example, turning circle of the wheelchair or space for a walking frame).
- The space required for transfers (mobile hoists are rarely suitable for long-term use in a bathroom and ceiling track hoists allow increased space for carers and equipment).
- Consideration is required regarding the width of the doorway, how the door opens, and the space required for this. It may be appropriate to arrange for a flip over type lock that can be operated from outside of the bathroom in the event of an emergency.
- It is important to take account of who else is going to use the bathroom and make sure their needs are accommodated. For example, are children in the family going to use the same facilities within the bathroom?
- Good lighting prevents falls, improves independence and improves hygiene and care (RNIB, 2020). Direct natural sunlight can produce glare, and, in this case, window coverings should be considered. A contrasting switch on the outside of the bathroom or a contrasting pull cord attached to the wall via a loop within the bathroom, can be easier to locate.
For occupational therapists working under the Disabled Facilities Grant Legislation, there is the need to balance what they assess as ‘necessary and appropriate’ and what the housing provider deems ‘reasonable and practical’. For example, if the occupational therapist recommends a 1500mm turning circle is required in the bathroom, the housing provider may advise that knocking through to an adjacent, unused room to extend the bathroom is more practicable than building an extension to the property. Robust clinical reasoning with a focus on occupation becomes critical when working within the constraints of legislation.
It is important to remember that occupation is defined as including ‘need, want and expectation’ (WFOT).
For those working outside this legislation or via alternative funding streams, it is important to allow a person to have choices and make informed decisions regarding the aesthetics of the bathroom.
There are a number of points to consider when considering toilet adaptations and determining individual need, including (but not limited to):
- Whether the dwelling is suitable for future potential adaptations.
- Cognitive ability of the person to use toilet flush or controls in the case of a wash and dry toilet, leading to exploration of control options.
- The activity analysis of physical ability to complete all aspects of the toileting process (see Closomat toileting activity analysis guide for more details).
- The user’s transfer method and how the toilet space can support this, including height (410mm as standard without plinth).
- Proximity of equipment and other bathroom items that may assist or inhibit transfer to and from the toilet.
- Sensory needs that require a change in standard colour or texture to support independence.
Ultimately the decision regarding conventional WC, bolt-on unit or automatic wash and dry toilet depends on the user’s ability to complete each part of the toileting process.
The white paper Guide to specification for wash and dry (shower) toilets (www.closomat.co.uk/resources/white-papers) covers toilet specification and considerations in greater detail.
The interactions between a person and their environment, in relation to tasks being engaged in, are crucial in ensuring that recommended adaptations meet the person’s long-term needs whilst maximising independence and engagement.
Points to consider within the environment include:
- Compatibility of the recommended adaptation with existing equipment. For example, the location of the douche on a wash and dry toilet needs to be appropriate to allow effective cleaning when using a mobile commode/shower chair.
- Existing drainage may restrict the options of re-siting the position of a toilet. If it is essential to relocate the toilet consider obtaining the advice of a surveyor to check whether this is feasible (some toilets – including wash and dry toilets – can be fitted with a macerator, which may help prevent such issues).
- Consider other aspects of bathroom design such as showering or bathing and whether recommendations within those spaces will impact on toileting. Each recommendation will have an impact elsewhere so see the bathroom space, and indeed the person, holistically.
- If a wash and dry toilet is included, it is recommended that it is fitted with an appropriate Residual Current Device but can be located within zone 1 of the bathroom (i.e. adjacent to the shower or bath), with the provision of a suitable curtain or shower screen to prevent direct line of spray. It is NOT recommended that the user showers whilst sitting on a wash and dry toilet.
What are Wash and Dry Toilets and how do they benefit the user?
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
Equality and Human Rights Commission, (2018) Housing and Disabled People: Britain’s Hidden Crisis, retrieved from: https://www.equalityhumanrights.com/sites/default/files/housing-and-disabled-people-britains-hidden-crisis-executive-summary.pdf (accessed on 10/01/2021).
Independent Living (2020) Accessible Housing Crisis, retrieved from: https://www.independentliving.co.uk/industry-news/accessible-housing-crisis/ (accessed on 10/01/2020).
Provan, B., Burchardt, P. and Suh, E. (2016) No Place Like an Accessible Home, retrieved from: https://www.lse.ac.uk/business-and-consultancy/consulting/assets/documents/No-Place-Like-an-Accessible-Home.pdf.
RNIB (2020) Adapting Your Home, retrieved from: https://www.rnib.org.uk/information-everyday-living-home-and-leisure/adapting-your-home (accessed on 30/12/2020).