Examining the function of Wash and Dry Toilets in delivering care for clients who have limited mobility and/or poor manual dexterity; how they promote and improve personal hygiene, reduce infection risk and the need for intervention by carers. And what to consider when building a specification.

Person learning to use their prosthesis.


We believe there is a demand for greater knowledge and under-standing of Wash and Dry Toilets and the key role they play in enabling Occupational Therapists (OTs) to build considered and appropriate adaptations around the needs of their clients in the bathroom.

This white paper has been created for OTs to assist them in providing the best possible care for clients with toileting needs. The specific focus is Wash and Dry Toilets and the important role they play:

  • In promoting and providing a higher level of personal hygiene.
  • In reducing the risk of infections.
  • In reducing or removing the need for carer intervention.
  • In enabling your client to live a more independent, happier life.

We will give detailed consideration to the following areas:

  • What are Wash and Dry Toilets and how do they benefit the user?
  • Key considerations when specifying Wash and Dry Toilets, covering the intended location and the user needs
  • The factors to consider in obtaining the correct seating position for optimum user comfort:
  • Toilet height
  • Toilet shape
  • Seat shape and size
  • Cleaning arm (Douching) positioning
  • How do Wash and Dry Toilets operate?
  • How to adapt Wash and Dry Toilets over time to address changing needs
  • The role of Shower Chairs in safe transfer
  • The importance of after-care and on-going support for the toilet and the user

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

Key considerations when specifying Wash and Dry Toilets

There are a number of different Wash and Dry Toilet solutions available to OTs, all providing different levels of support and performance.

Solutions vary from an accessory that bolts onto the existing conventional toilet through to state-of-the-art, purpose designed suites that incorporate flushing, washing and drying facilities in one toilet. Therefore, the first consideration is what level of care is appropriate for the client’s specific needs?

The length of time the toilet is expected to be in place should also be considered and how this might impact upon its continued suitability to the user – will it be able to meet the potential future needs of the user – can it be adapted or modified should needs change?

Another important consideration is the location of the toilet. Where will it go, what services (water and electricity) are nearby and how easy is it to access, both in terms of the installation and for transfer of the user to the toilet from a wheelchair. Under the Construction Design Management (CDM) Health and Safety Regulations, installations of Wash and Dry Toilets must follow specific procedures. So it is essential that a competent person undertakes the survey, and formally records specific information, such as access, water, gas and electricity shut-offs, and so on, prior to the installation.

All these considerations will have an impact on the cost of the solution to be specified. A thorough and detailed survey and assessment of the client’s needs and the intended site of the toilet is the best way to ensure a professional and cost-effective solution.


The user

Whichever option is being considered, the user has to be able to safely get on and off the toilet.

This may be independently, or by transfer from a wheelchair, via a hoist, a shower/commode chair, or a lifting device. The weight of the user is an important factor, so the load bearing rating of both the toilet AND the toilet seat (and its fixings) are crucial.


Achieving the correct seating position for the user

For a Wash and Dry Toilet to be effective, the seating position of the user is absolutely critical.

If they are not properly seated, they may be uncomfortable; they may be unstable and unsafe; and, crucially, they may not be properly “positioned” to receive the washing and drying cycles. Therefore, the shape and size of the user needs to be taken into account. The following factors should be considered when building a suitable specification for a user.


The toilet shape and height

The shape of the toilet should enable the user to sit comfortably, with their back supported against the cistern and their torso and legs forming a 90º angle.

This gives the most effective position and promotes bladder and bowel evacuation without undue strain. This position also ensures correct positioning over the pan/spray arm.

The toilet needs to be at a suitable height to accommodate the desired transfer technique. There can be a temptation to raise the height of the unit if the user struggles getting from sitting to a standing position. However, if the toilet height is raised too much, the user can become incorrectly seated, potentially affecting their stability and safety because their feet may not be firmly placed on the floor.

When reviewing transfer and toilet height, a more appropriate and safer alternative may be to opt for a toilet lifter or shower chair.

Furthermore, some Wash and Dry Toilets can be specified with appropriate support systems; for example, folding arms or lateral body supports. It is also possible, in some circumstances, to retro-fit an existing Wash and Dry Toilet.


The seat shape and size

The seat needs to be the correct size and shape, especially in bariatric or paediatric situations: buttocks need to be supported and slightly parted to enable the spray to meet and effectively clean the target area.

Closomat Lima Vita wash and dry toilet.

For bariatric users, the toilet seat and hinges need to withstand their weight for use day in, day out, without breaking or collapsing. A soft seat may also be an option, to give additional comfort whilst sitting.

For larger males, an open-fronted seat can help ensure correct positioning for effective cleaning.

Heated seats are available, but consideration of the user’s susceptibility to infection should be given as a warm environment can encourage growth of germs and bacteria.

For more information on bariatric and paediatric solutions – please click these links

Douching (spraying)

The douche (spray arm) position and extension are key to effective washing.

The positioning of the douche can be set in most cases to user requirements, to achieve the aim of washing the user effectively. Once set, it is not likely to be adjusted unless the user’s needs change. Ensure there is adequate clearance between the douche and the user’s bottom, for effective cleaning.

A standard douche will achieve good cleansing for most people who can attain a “normal” seating position. If a normal seating position cannot be achieved, an extended douche arm may be specified.

A dual spray version will deliver good cleansing when extra washing is required, for instance where users suffer from incontinence, or menstrual problems.

Douche specification and performance vary from manufacturer to manufacturer, so attention needs to be given to a number of factors:

  • The douche spray pattern varies and needs to be wide enough to cleanse effectively.
  • The flow rate of the water also varies: the more water that passes into the douche, the more efficient the clean. Some units use as little as 2l/minute, others up to 8l/minute.
  • Some manufacturers include the option to choose and vary the spray pattern and temperature.
For more information on douching – please click this link

Operation

When a user is going to the toilet without the assistance of a carer, they need to be able to operate it easily, especially if they have manual dexterity issues, or use a shower chair.

Bear in mind that toilet operation varies from manufacturer to manufacturer, so take this into account when considering your specification. For instance, some toilet controls are positioned behind and/or to the side of the unit, and can also feature small activation buttons.

Where bolt-on units are used (i.e bidet seats attached to a standard toilet), a conventional flush will be required before and after the douching process, which may even require the user getting off the toilet, turning round to flush, then manoeuvring back onto the toilet. Clearly, there will be circumstances where this is not appropriate for the user.

Operating accessories can be specified, such as a soft touch pad, a remote control or an infra-red proxy switch to help support a more straightforward user experience.

  • Flush pads can be used by most users, requiring only hand or elbow-pressure.
  • Where manual strength is limited, a soft touch pad may be more appropriate as it requires little pressure to trigger the flushing/washing process.
  • Remote controls enable easy operation by the user and/or a carer.
  • Infra-red proxy switches, if properly positioned, only require a small degree of limb control to ensure they are not accidentally triggered.

The location

Wash and Dry Toilets require an electricity supply, so new or additional cabling and appropriate fused spurs with RCD/protection may be needed.

If the toilet is being positioned in a bathroom or wet room, its proximity to a water source must be considered and appropriate regulations complied with.

Simply put, a Wash and Dry Toilet must have the appropriate IPX rating to be within a bathroom or wetroom environment. Additionally, so as to comply with water regulations, consideration must be given to the Wash and Dry Toilet’s WRAS Approval status – to fit a toilet that isn’t WRAS Approved is illegal.

Furthermore, modern Wash and Dry Toilets can be specified as floor-mounted, wall hung or bolt-on, so consideration will need to be given to any implications for installation. For instance, wall-hung units need to have a suitably strong supporting structure – a brick or block wall, or a frame.


Adaptability – dealing with changing user needs

People’s needs change over time.

A user may need only certain features of the toilet in the short-term, but their needs may change later. For example, they may only require the washing function initially but if their condition changes later, they could require additional support getting on and off the toilet, or they may lack the physical strength or dexterity to operate the controls.

Therefore, the flexibility of Wash and Dry Toilets and their ability to be adapted over time to changing needs should be a major factor in considering the specification.

The toilet design itself can influence its compatibility with additional independent living aids such as, but not limited to; shower chairs, toilet lifts, support seats. We’ll examine these in the following section.


Shower chairs

A Shower Chair with a Wash and Dry Toilet is the most specified piece of additional equipment, extending the versatility of the toilet beyond its organic functionality.

That being said, not all shower chairs are compatible with all Wash and Dry Toilets, so there are a number of things to consider:

Compatible size

When considering the use of a shower chair with a Wash and Dry Toilet the first and most basic consideration is that the chair fits all the way over the pan.

The height of the toilet vs the bottom of the shower chair

The gap between the top of the pan and the bottom of the chair’s seat must be as close as possible so as to ensure the effectiveness of the wash and dry functions. This may necessitate adjustments to the toilet height during the installation. Additionally, does the shower chair have a “skirt” on the seat aperture in order to stop splashes and keep the warm air in.

Methods of operation

Consideration must also be given to the chosen method of operation of the toilet, should the rear of the shower chair obstruct the primary flush/wash mechanism, for instance with obstructing cross bars or handles.

For more information on shower chairs – please click this link

Aftercare

Wash and Dry Toilets can be a complex piece of equipment, costing many thousands of pounds.

Like any complex piece of equipment, they can malfunction. The question to ask is what happens if things go wrong, or if further adjustments are required? Is it simply a problem for the user to deal with, or should this be factored into the OT’s thinking to ensure the specification caters for the user’s needs not just at the time of specification but also into the future.

What back up, service and support is available and how quickly and easily can issues be remedied? For most users, a Wash and Dry Toilet is life-changing and a crucial part of their daily routine, so if things do go wrong, a repair needs to be swift.

Some manufacturers offer annual servicing and maintenance – which can be included within the Disabled Facilities Grant – which could offer a solution to ensuring future needs are met without recourse to the OT, the local authority or, indeed, creating a headache for the user.

To download this white paper – please click here