What Makes a Bathroom Accessible?

By Don Epp, SARC Facility Planner

One of the most common inquiries I receive from Members is – how do I make our bathrooms more accessible?

Often an accessible bathroom is a deciding factor whether a resident can be supported in a home or not. In this article, I will review some ideas that have been successful in increasing bathroom accessibility in a group home.

Universal Design Concepts

Generally, one bathroom in a group home is required to be accessible when the whole home is classified as barrier-free. In homes that were not originally designed to be barrier-free, bathrooms can be renovated to be accessible using the National Building Code (NBC) as a guideline. The NBC addresses the minimum standard required. Accessibility is often personalized to meet the ability of the person using the bathroom. The Canadian Mortgage and Housing Corporation (CMHC) suggests a few universal design concepts to guide changes or renovations to create bathrooms that can accommodate everyone in the home now and can adapt as people age. These concepts are:  

• Size of bathroom– a larger bathroom offers more space for maneuvering, especially if another person is needed for assistance. A minimum of a 1500mm turning circle is required for wheelchairs. Space is also needed in front and beside fixtures for access.   More space is needed if using a ceiling lift, as staff are required for support. A change table may also be needed for personal care, which will also require more room.
• Bathroom layout – the positioning of the tub or shower in relation to the toilet and sink make maneuvering between the fixture that much easier. The placement and location of grab bars and bathroom accessories is also important. Sometimes it is necessary to have a space on both sides of the toilet for staff to support an individual.
• Framing – when renovating a bathroom it is important to plan where all the fixtures and accessories are going to be placed. Extra blocking in the walls is needed to add enough support to attach grab bars. Adding ¾” plywood to the framing will help with future changes to the bathroom as grab bars and other accessories can be moved to meet changing needs of the residents. Additional framing in the floor or ceiling must be considered if adding a large therapeutic tub or ceiling tracks.
• Adaptability – designing an accessible bathroom also means that there could be multiple people using the bathroom, each with different preferences and needs. Hand held movable showerheads, drop down grab bars, knee space under sinks, lower switches and controls, hands-free taps, contrasting colours to aid those with visual limitations, all help to address varying needs in a bathroom.
• Ease of cleaning – cleaning is important especially if there are many people using the same bathroom. An adequate bathroom fan is important as it removes excess moist air and prevents the buildup of mold and mildew. 
• Safety – falls and extreme hot water are the most common hazards in a bathroom. It is important to have non-slip flooring with appropriately placed grab bars. Hot water mixing valves or anti-scald devices in tub and shower controls will reduce burns. It is also important to have ground-fault (GFCI) electric plug-ins near sinks.

Bathtub or Shower?

Whether to install a tub or a shower in an accessible bathroom is often a topic of great debate. One or the other is required in a group home.  Some homes have both a tub and shower in one bathroom, and other homes have more than one bathroom with either a tub or shower. There are a variety of options with tubs and showers, so how does one decide which to install? Some consideration can be placed on who is going to be using the tub or shower. In addition, consideration could be given to the size of the tub and the space required or if the water heater can supply enough hot water. There are advantages and disadvantages with both, and it is best to understand the different options of tubs and showers and how they can best serve the residents in the home.

Tubs

Standard tubs ($300-$800):

Standards tubs are the most common residential tub (30”x60”). These are often installed into an alcove with access to the tub from one side. These tubs can come with a whirlpool or water jet function ($1500-$2500) or an air jet system ($3000-$4000). Tub showers ($1000-$2000) also fit into this category.

Pros:

• These tubs are versatile:
  • Can serve ambulatory and non-ambulatory people.
  • Can be installed on a stand or in the center of a room when a lift is available for entry/exit.
  • Can shower standing or seated on a bench.
• Water or air jets offer therapeutic massage options.
• Shower benches are available for transfer to bath from chair. Staff can easily assist a person on a shower bench with the use of a hand held showerhead.
• Lift chairs are available that can lower an individual into the bath and raise them out of the water.

Cons:

• Tubs have a large step to enter/exit the tub (around 16”). Must be able to lift leg over edge of tub.
• Staff may find it difficult to assist someone seated at the bottom of the tub. 
• Water jet tubs need cleaning and disinfection after every use because bath water can remain in the pipes and be transferred from one bath to the next.

Recommendations:

Standard tubs can be good for assisting people with limited mobility, if there is space on both sides of the tub and a ceiling lift is available. Air jets add a therapeutic option that aids in the relaxing bath experience. If the tub is raised off the ground then it may be more difficult for fully mobile residents to use.

Handheld showerheads increase the versatility of tub showers for people with limited mobility. One-piece tub showers with integrated grab bars are the best for leak protection. Two and three piece tub shower kits are also very good at keeping the water in the tub.

Not Recommended:

Due to the potential for health concerns with water jet tubs, this feature is not recommended. If water jets are important, there are “self-purging” ozonator models available to eliminate mold and bacteria growth in the pipes.

Separate, glue on the wall tub surrounds are not recommended due to the potential for leaks between the surround and the tub.

Avoid tub cuts, where the existing tub is cut to install a low access door. These are prone to leak.

Walk-in (slide-in) tubs ($5000-$8000):

Walk-in tubs have a door that opens inward and slide-in tubs have a door that opens outward (both are often 30”x48”).

Pros:

• Has a door for easy entry.
• Options of a heated seat and air jets.
• Many options for door configuration. Most common in group homes is the outward swinging door that allows a transfer from wheelchair to bath seat.
• Can be used with a ceiling lift.
• Saves space in small bathrooms.
• A handheld showerhead and factory build tub surround can be added to help with hair washing and cleaning the tub after a bath.

Cons:

• Doors can be opened prematurely and flood the bathroom. Floor drains are recommended.
• Tub is filled (and drained) while person is seated in the tub. Attention must be given to the water temperature during filling.
• Larger water supply lines (3/4”) and a larger drain (2”) are required to shorten the fill and drain times.
• Seals on the door need to be replaced periodically.
• Soaking neck and shoulders is difficult in a slide-in tub as the person is seated during the bath.
• Support staffmay have difficulty assisting a person in the tub, especially with washing their feet.

Recommendations:

Slide-in tubs with an outward swinging door that expose the seat can be used by people of all abilities. These tubs have been used with success in many group homes. It is very important to have a floor drain installed for this style of tub.  Tubs with inward swinging doors are not recommended.

Therapeutic Tubs ($25,000-$35,000):

Therapeutic tubs are specialty tubs designed for people with low or no mobility. These high quality tubs require staff to assist with operating the tub.  Roughly 45” wide and up to 8’ long.

Pros:

• Offers maximum therapeutic experience to the resident.
• Resident can lie flat in the water.
• Water temperature is regulated and many of the controls are automated.
• Cleaning and disinfecting solutions are self-dispensing in clean mode after every bath.
• Easy to assist resident in the tub as the entire tub can be raised or lowered.
• Options of integrated weigh scales to monitor weight of resident.
• Bariatric residents can use these tubs.Therapeutic Tub

Cons:

• A large room is required, 12’x12’ or larger is recommended.
• Must be used with floor lift supplied by tub manufacturer or a ceiling lift.
• Staff must assist with use of the tub, not recommended for independent use.
• Special cleaners are required by some manufacturers.
• Some replacement parts are not readily available causing delays when a repair is needed.
• Plumbing changes for faster fill and draining and a larger hot water heater are recommended.

Recommendations:

Therapeutic tubs are widely used in nursing homes and in group homes. They are designed for easy and efficient bathing options that benefits residents who need full assistance. The trend now is to convert tub rooms to spa rooms as some tubs have options for music and tub lighting. Cost of the tub and accessories and the size of the room required are often the determining factors when purchasing this style of tub.  Availability of replacement parts and cost of cleaning solutions should be considered before choosing a therapeutic tub. These tubs are the best option for people who need the most assistance.

Showers

Curbless Showers:
Curbless showers (36”x60” minimum size for accessible shower) have a low access threshold where wheeled chairs can easily enter the shower. These can be pre-fab models with a shower pan ($3000-$5000) or custom-built ($4000-$6000) to fit the dimensions of the room. Non-slip flooring, grab bars and scald controls are important in all showers. Trench drains are innovations that can make custom curbless showers easier to maintain.

Pros:

• Zero threshold makes it easy to roll a chair into the shower.
• Shower controls and adjustable handheld showerhead can be installed at any height to accommodate seated and standing users of the shower.
• Staff can assist with the handheld showerhead.
• All members of the house can use the shower.
• Seats and grab bars can be integrated into the shower.
• Custom showers can be built to fit in any bathroom.

Cons:

• Water can escape the shower into the bathroom, floor drain recommended.
• Staff may get wet when assisting a resident in the shower.
• Tiled showers with many grout lines may be difficult to keep clean.
• Corners in showers are often difficult to clean.
• Shower doors or curtains may affect the use of ceiling lifts.

Recommendations:

Showers offer a different experience than bathing. Showers are often quicker and require less prep and clean-up time People with low mobility may require a shower chair and a lift. Curbless showers offer good choices for accessible bathrooms in group homes.

Wet Rooms:

Wet rooms are entire bathrooms that are designed to get wet. Ceilings, walls and floors are all waterproof.  Often, there is minimal separation between the shower and the rest of the room. Non-slip flooring with sloping floors and adequate drains are important in keeping the sub-floor dry. Cost is more than a custom curbless shower as it varies with size of room and finishes.

Pros:

• More room for maneuverability and assistance without shower enclosures.
• Smaller bathrooms could become wet rooms.
• Can be used by all the residents of a house.
• Increases the design options of a bathroom.
• Ceiling lifts could be used.
• Entire room is waterproofed.

Cons:

• Expertly installed waterproofing is very important to prevent water from seeping out of the wet room. Will add extra costs.
• Storage of “dry” or electrical items may need to be located in another room. More humidity in a wet room than a bathroom with a shower.
• On-going cleaning is needed to keep it tidy and free of residual moisture.
• May be cooler than a contained shower as heat dissipates throughout the room.

Recommendations:

Shower screens are recommended to help contain the water from the shower. Wet rooms are similar to a custom curbless shower. A wet room is a good accessible option for a bathroom. With multiple floor drains, all spilled water finds its way to a drain.

In general, tubs and showers offer different experiences for residents. Some residents benefit from a relaxing bath, immersed in warm water. Others feel a cleansing shower is best for them. Staff assisting with bathing routines have their opinions as well. Often the bottom line in choosing a tub or a shower option is space, cost and meeting the needs of the residents on a long-term basis. The ability to adapt to the changing needs of the residents over time is also an important consideration. For more information on accessible bathrooms, HomeAbility is a great resource.