Beyond the care home walls: how organisational and neighbourhood environments influence community access for residents living with dementia.

Maintaining meaningful access to the surrounding community is increasingly recognised as a key component of well-being, quality of life, independence, identity, and social citizenship for people living with dementia. Institutions often act as gatekeepers, mediating residents' access to the surrounding neighbourhood. Yet little empirical evidence exists on how residential care facilities act as institutional mediators of of residents' access to the neighbourhood beyond the institution's premises. This cross-sectional study draws on survey data from 423 directors of Portuguese care homes to examine: (i) the extent to which residents with dementia are permitted to go outside and under what conditions; (ii) how frequently they engage in individual and institution-organised outings; and (iii) the organisational and environmental determinants associated with these practices. Three logistic and one ordinal regression models were conducted, reflecting different conceptualisations of "going outside", from independent mobility to the frequency of structured outings. Overall, the findings indicate that outing opportunities are strongly shaped by organisational culture, staffing structures, staff training and awareness, facility ownership, and the local environment. For-profit facilities were consistently more restrictive across several models. Higher person-centred care scores, the availability of facility-owned transport and dementia-relevant staff training were associated with greater freedom or more frequent outings. Environmental perceptions also played an important role: directors who considered the surrounding area to be quiet or green tended to permit more liberal access and reported higher frequencies of outings. These results highlight the multilayered nature of community access in dementia care and underscore the need for integrated policy approaches that address organisational resources, workforce capacity and capability, and neighbourhood environments to support the independence and social participation of residents living with dementia.