In addition, green environments provide meaningful activities in which people with dementia are interested in engaging and can consolidate self-esteem.” (Rappe and Topo 16, p. 224, author interpretation) Some studies reported barriers that Ganetespib limited the access residents (and in some cases staff) were able to have to the garden. Concerns about physical safety meant that staff did not always feel able to let residents use the garden as often, or for as long, as they wanted: Member of staff – “We all have concerns at this point in time about the environment outside – we have nice walkways, nice shrubs, nice trees – with stakes at

the moment – and we kind of wondered whether a level ground would have been better, just grass. We’re kind of concerned that they’re walking over the bushes and might trip and fall.” (Morgan and Stewart 29, p. 110, edits in the original) This may have been particularly the case for newly opened gardens that still had the structural materials of the gardens showing: “…safety of the outdoor patio area of the new

ground floor SCUs was a concern when it first opened. Shrubs, sprinkler systems, stakes and wires supporting new trees and uneven surfaces were identified as potential hazards…” (Morgan and Stewart 29, p. 110, author interpretation, reviewer edit) These restrictions find more seemed to reflect general care home practices and capacity of staff: Member of staff – “I do appreciate the fact that they allowed them the freedom to be able to go outside… [but] it creates quite a havoc for us to be watching them when we don’t have the staff to do that.” (Morgan and Stewart 29, p. 110, edits in the original) The availability of staff to spend one-to-one time assisting residents in the garden in current work settings may be limited;

NADPH-cytochrome-c2 reductase this is highlighted in one study in which the staff-resident ratio was reported to be very poor.16 Residential homes may be difficult to adequately staff to the extent that visits to the garden are at best assisted and at worst observed; in some homes the garden was not even visible from any inside space.29 As reported here, it is sometimes the case that residents are asking or trying to get out but are not permitted because of a lack of staff or the risk that they may fall.25 In these cases, it appears that staff do want to help, but feel the system does not allow it or that it is not a priority in their caring role. In one study, the garden was used by staff who were smokers, which made it a less pleasant place for other staff and seemed to prevent some people from using the outside space: Member of staff – “I usually take my breaks inside. I don’t go outside … because I’m not a smoker. It’s a nice garden space, so you would think I’d want to go outside, but I don’t, because I don’t smoke. Other employees use it because they go out there to smoke.” (Hernandez 25, p.