The deceptively simple look of a pioneering new autism inpatient unit belies the highly complex set of spaces within, painstakingly designed for a very specific clinical need and helping patients return to the community. James Parker reports.
Mitford autism inpatient unit in Morpeth, Northumberland, is the first purpose-built care facility of its kind, and a building designed to tackle a very specific challenge. The residential unit serves adults with severely complex autistic spectrum disorders, for which a new healthcare methodology has emerged which looks beyond managing their conditions for the long-term in NHS facilities to a much greater focus on helping them move back into the community.
Due to the nature of the patients’ conditions, the unit is a particularly resource-hungry one, and this was one of the challenges for the Northumberland, Tyne and Wear NHS Foundation Trust and its architect, Medical Architecture. Despite the practice’s solid credentials from designing several notable mental health schemes, and its client being one of the UK’s largest mental health trusts, this project was demanding to say the least.
The unit at Northgate Hospital was established to provide care for people who mainstream mental health services struggle to accommodate, including some who may have been placed in secure units. Patients’ conditions can see them being destructive or even violent, so caring for them means a standard staff-patient ratio of four to one, making them ‘high tariff’ by NHS standards. The design of spaces needed to be carefully considered to provide both a therapeutic environment and also one that is robust enough to withstand attack.
The trust hoped that a carefully designed environment could minimise adverse reactions and help users progress back to the community, ideally between 18 months and two years from admission. The highly specialised nature of this project made the client anxious however; it was building a unit costing £10m for 15 patients, with a design which would be hard to adapt to other uses, so it had to deliver on its business case. As project architect Paul Yeomans tells ADF, “Developing the brief was difficult, because the trust was nervous – what if their tender was taken away, they’d be asking ‘what do we do with this now?’”
Part of the business case was that there was a “correlation between the environment and positive patient outcomes,” however there was also very little precedent when it came to designing the unit. The only other similar provision in the UK is at the Maudsley Hospital in south London. The design team had to harness all of its own experience, which included an NHS autism unit in Caterham, Surrey, as well as seeking advice from the National Autism Society, and immersing itself in research and clinical consultation to identify the answers. Medical Architecture has a longstanding relationship with the trust behind the project, designing mental health schemes for 12 years, begin- ning with a £25m unit in Gosforth with Laing O’Rourke delivered through NHS Procure 21.
The practice’s strong relationship with the client was key to helping it develop the brief – as well as it having a Newcastle office, set up 11 years ago as an addition to its original London base partly to support the trust’s projects. For this scheme it was working with contractor Kier within the current NHS Procure 21 framework (Procure 21+), and it would prove to be one of the most testing projects Medical Architecture has tackled. Helping the client get to the point that “everyone was comfortable” with the design brief and attendant business case took two years.
The architects visited autism units in the UK and reviewed projects in the US, to better understand the care methodology and how service users experienced their environments. Yeomans candidly admits that visiting the trust’s existing facilities was difficult: “It’s often quite alarming to see the realities of what this condition is all about, patients will hit their heads against walls, or isolate themselves because they don’t want to communicate.” He adds, “you’d see aggressive incidents, it’s quite difficult to deal with.”
Given the fact that the substantial numbers of clinical staff at the unit worked closely with service users, the architects “relied on them to guide us on what a good patient environment was,” says Yeomans. The architects used a client briefing methodology they had successfully applied in other projects to discover staff working practices so they can optimise the design to varied needs. Called ‘Perfect Day’, it consisted of a half-day workshop “with a lot of people in the room,” says Yeomans, from head clinicians to cleaners, describing what their work consists of throughout the day.
The findings are then fed back to all staff, increasing the sense of ownership of the design, and this forms the beginnings of the brief. Yeomans explains: “You turn these into diagrams, and get to a point where people are happy and understand the fruits of their labours.”
This kind of in-depth consultation was crucial in identifying the key design drivers for such a building, including the ‘thresholds of space’ that are critical for the facility’s service users. Yeomans explains further: “Patients need to prepare themselves to move from one space to another. We created seating spaces along the circulation corridors enabling them to see where they were going to sit, and once they are there, they can see where they’re going to go afterwards.”
The unit represents a change in the clinical model to assessment and treatment, so that, in Yeomans’ words, “there was a pathway for patients to move on.” He says: “This was quite a sea change, previously they could have been in here for long periods.” The unit replaces the provision at a 1970s building nearby which unlike the Mitford unit, was not purpose-built, and had been “doing the best it could,” says Yeomans, with the typical NHS piecemeal additions over the years.
As Yeomans says, while the building “looks quite simple, it’s actually incredibly complicated.” The accommodation is divided into single and shared flats, in four ‘fingers’, with corridors running north-south along-side rooms and east-west across the top and bottom creating a loop to help staff easily get from one finger to the next. Shared ancillary spaces are ranged along the south flank of the building, including multi-disciplinary team meeting rooms, activity space, a kitchen for occupational therapy, and staff rest areas.
The flats in the two easterly fingers are generously proportioned, and patients live in these when they first arrive. The overriding aim is that as their ability to socially interact with others improves, they move to the smaller individual bedrooms in the other two fingers, which also have shared lounges. Then following assessment they will be able to go back into the community.
Between the fingers are outdoor spaces, and all of the flats have their own access to a private ‘garden,’ laid with 4G artificial turf due to difficulties in maintaining these ‘landlocked’ secure areas. In the westernmost finger, the gardens are shared with other patients, as they get used to spending more time with people, and this is not only a therapeutic amenity, it’s also a cost-effective one.
The unit’s Kalzip aluminium roof unifies the building visually, and also overhangs slightly over gardens to enable patients to sit outside in inclement weather. The roof was an important design feature for staff, to help simplify and clarify its form, says Yeomans: “Because we have quite a complex plan going on, we thought we needed to put a sort of top hat on the building to try and contain a lot of that. Even from the outside people can tell where they are – all the gables come to the end of the building and it’s immediately apparent there are four fingers.” As is common in such sensitive units, M&E servicing access is located in the roof space to avoid any disruption to the spaces below.
The trust funded the construction of a full-sized mock up of a flat, which, says Yeomans, “was invaluable to just test things, work out of sizes were right, and we were able to get things like ironmongery and the kitchen workbench sorted out.” When the building was finished, a group of project team members including estates management, clinicians and Yeomans himself stayed in the unit to see if there were any glitches or equipment faults that
could be resolved, as this would be hard to do once patients had moved in. Designing the flats in close co-operation with clinicians and using Revit ensured that they could be planned out in fine detail.
The corridor design is where some of this building’s complexity emerges, as they are broken up at each flat door by square ‘knuckles’ which on plan continue the line of flats obliquely across the corridor to form seating areas adjacent to each door. As part of tackling users’ ‘threshold of space’ needs, staff can sit here whenever needed, as part of monitoring a patient, have a conversation with colleagues, or sit with patients as a stop-off as they move through the unit. The design provides a high level of flexibility for the staff, as Yeomans says: “Staff can take activities to the patient in the room, sit with them in their lounge, or retreat to the circulation space outside and keep an eye on them.”
Environmental conditions such as lighting and heating can be controlled individually via electronic panels mounted outside the flats. This is critical because severely autistic patients may not respond well to ‘normal’ temperature parameters and they may need precise adjustment by staff to make a room colder than usual, for example.
The overall goal of the architects was to create a “calm and protective setting that offered comfort and privacy for residents.” Part of this is balancing the requirements for daylight and views with the need to ensure that patients are not disturbed by being overlooked. While the patients have views from their flats via their private garden, they are not overlooked within them, and all flats are oriented in the same direction (facing east) to ensure similar light levels through the day for all patients.
In circulation corridors, high level windows avoid overlooking the patients’ gardens, but enhance the spacious feeling of the corridors, and also avoid glare for patients. The ambience is helped by natural ventilation and the rounded corners in corridors (although the principal reason for these is safety). The building is rated BREEAM Excellent – thanks in part to its natural ventilation but also the addition of renewables including air source heat pumps and PVs on the roof, plus locally sourced materials.
User safety also meant that blinds were not an option in patients’ flats and bedrooms, and instead Medical Architecture devised a sophisticated lock-back timber shutter which recesses into the wall to reduce the risk of it being damaged by a patient. Shared patient lounges have TV and storage units which can be enclosed and locked shut by staff behind specially created joinery doors if necessary. Yeomans says the decor is deliberately minimal, and “pretty bland”, this is important to avoid overstimulating users – “it wasn’t that we like beige,” he remarks. The idea is that the resulting low-key feel of the environment is a starting point from which clinicians can build, as they work to discover what works with each particular patient.
When it came to acoustics, one of the aspects that emerged from the mockup of a patient flat was that walls needed to sound ‘solid’ to users to discourage damage by patients, and the modular SFS frame – plus ply and plasterboard – would be a challenge on this front. Therefore a sandwich of different plasterboards and insulation were tested before an affordable solution was arrived at which sounded as robust as blockwork when knocked.
The building won the Best Mental Health Development in the Building Better Healthcare Awards 2017, and was Highly Commended in the European Healthcare Design Awards 2017. The judges of those awards commented on how the unit successfully combines resilience with care: “The project provides a robust and effective working environment that is compassionate to the resident group.” The staff have high praise for the effect of the new building on users – ward manager Pamela McIntyre said: “We are witnessing huge impacts on quality of life. Seeing a mother reacting to her son having his first incident-free day in seven years is very rewarding.”
Medical Architecture’s Paul Yeomans says that the client seems “really satisfied” with the unit, now that it has been in operation for a year. “It’s still early days, but there seems to be a lot of good evidence coming out of it.” Of course the ultimate testimony of such a specialised healthcare unit is from its clinicians, and the users, although in this case the latter have difficulty expressing that. However according to one staff member, whereas in the previous building one patient “lived in self-imposed isolation and crawled everywhere, within a week of moving into Mitford he was having a drink with staff in one of the offices.”
Project Suppliers: Mitford autisM inpatient unit
Acoustic insulation: Ecophon
Aluminium roofing: Kalzip
Ironmongery: Primera and Laidlaw
Partitions: British Gypsum
SFS frame: Orca