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The Dementia Green Care Handbook of Therapeutic Design and Practice is a practical guide to designing and using outdoor spaces with people who have dementia. It treats gardens and contact with nature as person-centred care opportunities: activities should reflect an individual’s history, preferences, abilities and current needs. It is not a clinical treatment protocol, and it does not show that gardens cure dementia or slow its progression.
For a care home, day service, extra-care scheme or family caregiver, the handbook’s central lesson is operational as much as architectural. A garden only becomes therapeutic when the setting, activity, staff support and leadership make it possible for a particular person to use it meaningfully.
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What the Dementia Green Care Handbook covers
Garuth Chalfont and Alex Walker’s handbook was first published in English in 2013 by safehouse books. It grew from the “Therapeutic Dementia Care” design and research project, funded by the Health, Innovation and Education Cluster at Central Lancashire PCT, with Age Concern Central Lancashire as a delivery partner. NHS Central Lancashire and the HICA Group were also listed among the collaborators.
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The project set out to move beyond advice about how a garden should look. It examined how outdoor spaces could be used actively in dementia care, including when a person is distressed. The handbook therefore brings together therapeutic thinking, environmental design and day-to-day practice. Its audience includes care-home operators and managers, nurses and support workers, landscape and architectural designers, commissioners, families and people working in residential, nursing, enhanced day-support and extra-care settings.
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The author’s framework describes nature as therapeutic and the garden as a healing tool. That is the handbook’s practice model, not a statement that gardening is a medically established treatment. The useful question for a project team is how a person experiences a place and what support enables that person to take part.
What “green care” means in a dementia setting
Green care in this context means purposeful contact with nature outdoors. It can include tending plants, walking, sitting in a familiar spot, noticing seasonal change, visiting a garden with support, or taking part in a social activity outside. The activity does not have to involve horticultural skill. Someone who once maintained a large garden may want to prune or sow; another person may prefer watching birds, smelling herbs or helping set a table outdoors.
This distinction matters because imposing “gardening” on everyone defeats the person-centred approach. NICE quality standard QS184 says services should offer activities that promote wellbeing and tailor them to a person’s life experiences, circumstances, preferences, strengths and needs. Gardening is listed as one example alongside exercise, art, baking, reminiscence and music. The recommendation is to adapt activities, not to prescribe one activity or one garden layout for every resident.
What the evidence says about gardens and dementia
Evidence is encouraging but still uneven. A 2023 systematic review by Melanie van der Velde-van Buuringen, Rosalie Hendriks-van der Sar, Hilde Verbeek, Wilco P. Achterberg and M.A.A. Caljouw examined garden use in nursing homes. It included 19 publications describing 17 studies. The studies covered purpose-designed gardens, outdoor activities, garden visits, seasonal comparisons and different arrangements for access.
The review found that early studies suggest possible improvements in quality of life, behavioural and psychological symptoms, stress, sleep or mood. However, the interventions and outcome measures varied substantially. The authors called for more consistent measurement and for evaluations to account for physical, social and organisational factors. The number of studies is therefore not proof that a particular design works for every person.
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A 2018 observational study at a UK dementia care facility reported that exposure to a nature garden was associated with beneficial changes in mood among residents with mid- to late-stage dementia. Because this was an association in an observational study, it cannot establish that the garden caused the change. It also does not show that gardens treat dementia or modify its progression.
| Source | What it examined | What can reasonably be concluded | Important limit |
|---|---|---|---|
| 2023 systematic review | 19 publications describing 17 nursing-home studies | Early evidence suggests possible benefits across mood, stress, sleep, behaviour and quality of life. | Methods, interventions and measures were heterogeneous; stronger, more consistent evaluation is needed. |
| 2018 observational study | Nature-garden exposure in a UK dementia facility | Exposure was associated with mood improvements in residents with mid- and late-stage dementia. | Association does not prove causation, treatment effect or slower disease progression. |
| NICE QS184 | Activities intended to promote wellbeing | Gardening can be offered as one tailored activity among several options. | The standard does not specify a universal garden design or activity timetable. |
How to turn the handbook’s principles into a care plan
1. Start with the person, not the planting scheme
Build a short profile for each person who may use the outdoor space. Record previous occupations and hobbies, plants or places they remember, preferred levels of company, mobility, communication style, sensory likes and dislikes, and times of day when they are most settled. Include what the person can do independently and what assistance, prompting or supervision is needed.
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Use observation and conversation with the person, family and staff. A preference can change with fatigue, pain, weather or stage of dementia, so treat the profile as a working document rather than a permanent label.
2. Map the route and the support required
Review the complete journey from the person’s room or communal area to the garden and back. A design team and care team should identify thresholds, confusing junctions, narrow points, places to rest, visibility for staff, lighting and weather exposure. The handbook does not prescribe one dimensional standard; the practical test is whether the person can reach and use the space safely and with dignity.
Decide who opens the door, who accompanies a resident, how independent access is monitored, and what happens if a person becomes distressed or wants to return inside. A beautiful garden that is locked, difficult to reach or unsupported in practice is not a therapeutic resource.
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3. Provide more than one way to participate
Plan a range of options rather than a single gardening session. Examples include a short walk, sitting with a drink, watering, sorting leaves, planting seeds, smelling familiar herbs, listening to birds, helping with a seasonal display or joining a small social group. Offer observation as a valid form of participation; not everyone needs to touch plants or complete a task.
Match the task’s complexity, duration and physical demand to the individual. Break activities into visible steps, demonstrate rather than rely on verbal instructions, and stop when the person shows fatigue or distress. Adapt tools, containers and work surfaces only when an assessment shows they help that person; no item is medically required by the handbook.
4. Make access a routine, not an occasional event
Leadership should decide when outdoor access is offered, how it is recorded and how cover is maintained during busy periods, weekends and bad weather. The handbook foreword emphasises that design, staff training and encouragement from leadership are all needed to make therapeutic practice a norm within a care setting.
Include outdoor use in handovers and activity planning. If a resident’s mood, sleep or engagement changes, note the circumstances: time outside, activity, company, weather, assistance and the person’s response. This creates a basis for adjusting support without claiming that every change came from the garden.
Designing the space: questions for construction and care teams
The handbook is not a building regulation or a universal specification. A construction or landscape brief should therefore begin with the people and routines the setting serves. Useful questions include:
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- Can residents reach an outdoor area from the main living spaces without an unnecessarily complicated route?
- Are entrances, paths, seating and activity areas understandable to people with different mobility and orientation needs?
- Can staff see enough of the space to offer help while preserving privacy?
- Are there places for quiet one-to-one use as well as group activity?
- Can the space support brief visits as well as longer sessions, with opportunities to rest and return indoors?
- How will the garden remain usable across seasons, changing daylight and variable weather?
- Who will maintain planting, surfaces, furniture and equipment, and how will defects be reported?
These are design-and-management decisions, not evidence-backed claims that one feature guarantees a health outcome. Test proposed layouts with residents, families and staff before construction where possible, then review how the completed space is actually used.
Independent reader supportYour contribution helps us test, update, and keep practical guides available for everyone.Choosing between outdoor approaches
Different approaches can serve different people. Compare them by the support they require, their fit with personal interests and the outcomes you intend to observe.
| Approach | Best suited to | Support questions | What to measure |
|---|---|---|---|
| Purpose-designed garden | Regular access for residents with varied interests and abilities | Can people reach it, understand it and find staff help when needed? | Who uses it, how often, for how long and for what purpose. |
| Supported garden visit | People who benefit from outdoor contact but cannot access it alone | Which staff member accompanies the person, and what happens if distress or fatigue occurs? | Engagement, comfort, mood and the person’s stated or observed preference to return. |
| Structured horticultural activity | People with an interest in practical tasks and a suitable level of ability | Can the task be simplified, paced and adapted without turning it into a test? | Participation, enjoyment, effort and whether the activity remains meaningful. |
| Seasonal or observational use | People who prefer brief, sensory or reminiscence-based contact | Are there comfortable places to pause and sufficient time for noticing and conversation? | Response to the setting, social interaction and preferred duration. |
The 2023 review’s emphasis on physical, social and organisational context is important here. Two gardens with similar planting may produce different experiences because staffing, access rules, resident mix and daily routines differ.
How to evaluate a programme responsibly
Set a small number of practical measures before changing the space or schedule. Record participation, duration, assistance, activity type and the person’s response. If the care team tracks mood, agitation, sleep or quality of life, use the same approach over time and note other relevant changes, such as medication, illness, staffing or unusual weather.
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One free scan finds every outdated or missing driver and matches the right update for your exact hardware.Free scan · exact hardware matchInvite the person’s own account whenever communication allows. Family observations and staff notes can add context but should not replace the person’s preferences. Review findings with the multidisciplinary team and change the activity or access arrangement when it is not wanted or is causing distress. Evaluation should improve care, not be used to promise a clinical effect that the evidence has not established.
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Common implementation failures and how to correct them
The garden is attractive but rarely used
Check opening arrangements, route complexity, staffing and whether anyone has responsibility for inviting residents outside. Add a named owner for access and include outdoor opportunities in daily planning.
Everyone is offered the same gardening task
Return to the person’s life history and preferences. Offer observation, conversation, walking or a different sensory activity, and accept that declining is a valid choice.
Staff see outdoor time as an optional extra
Use training and leadership messages to explain the purpose, demonstrate safe support and make expectations explicit in handovers and rotas. Alex Walker’s foreword identifies design, training and leadership encouragement as mutually necessary.
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Record context and use cautious language such as “associated with” or “the person appeared more settled after.” Consider competing explanations and avoid describing the activity as treatment or disease modification.
Which editions are available?
The original English edition is the first edition published by safehouse books in 2013, ISBN 978-0-9744912-1-9. Garuth Chalfont’s author website provides a PDF download. A German translation, Praxishandbuch Dementia Green Care, was published by Hogrefe in 2024, ISBN 978-3-456-85564-6. These are different language editions; check the catalogue or seller’s current information for format and availability.
Who should use the handbook?
It is most useful when several roles read it together: managers who can set routines and resources, care staff who know residents’ daily responses, designers who shape access and visibility, maintenance teams who keep the space usable, commissioners who define service expectations, and families who can contribute life-history knowledge. Used this way, the handbook supports a realistic goal: making nature and outdoor activity available as one personalised route to engagement and wellbeing, rather than presenting a garden as a cure.
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