Resource Pack for Action Plan
SPACE principles / Potential Ideas forAction Plan / Resources / Outcomes
Comprehensive dementia toolkit resources for GPs /
STAFFwho are skilled and have time to care
Enhanced staff knowledge and understanding / Staff to become Dementia Friends
Consider giving each member of staff “A Guide for Customer Facing Staff” from the
Alzheimer’s Society
Staff Tier 1 trained training / Dementia Friends,
Customer Facing Staff handbook;
(costs £5+p+p for 25 booklets or free to download)
Health Education Thames Valley Tier 1 training sessions;
Tier 1E-learning resources
1.National Skills for Health training, Stand By Me ( Free)
2. e-Learning for Healthcare ‘e-Dementia: Introduction to Dementia’ course.
3. Social Care Institute for ExcellenceOpen Dementia programmewhich is free to access.
4. Blue Stream Academy Dementia awareness ( available through practice based Blue Stream Academy ( fee for the academy licence, dementia module is free) / 95% of staff to become a Dementia Friend
90% of staff to be Tier 1 trained
Clinical Lead(s) to be Tier 2 trained
SPACE principles / Potential Ideas for
Action Plan / Resources / Outcomes
Improve GP knowledge of local pathway / Arrange a clinical meeting with your local Mental Health for Older People Consultant to discuss the CCG dementia pathway and the resources available locally. / CCG can help to arrange at practice or Locality Meetings
Nominate a Clinical Dementia Lead / Name and contact to SCN and CCG. / A lead Clinician is identified- SCN/CCG informed
Nominate a Practice Champion / A member of staff to be responsible for signposting dementia patients /carers to suitable resources. / Can be a non-clinical member of staff / A Champion is identified
Mental Capacity Act Training, safeguarding / To ensure that all members of staff have completed the MCA and safeguarding mandatory Training. / National Skills Academy for Health training;
/ 90% of staff have completed training
Practice to register for their local Alzheimer’s Society Newsletter / Receive the newsletter and the resources that are available locally; Singing for the Brain, memory Cafes, support groups etc.
Dementia Connect. /
Dementia Connect is Alzheimer's Society's comprehensive services directory for people affected by dementia in England, Wales and Northern Ireland.
Enter your postcode or place name to find voluntary, statutory and private services nearest and most relevant to you. Each listing includes a map and clear, essential information about that service.
If you would like to find your local Alzheimer's Society office please use the officesearch.
SPACE principles / Potential Ideas for
Action Plan / Resources / Outcomes
Publish Dementia resources on practice website – e.g. DAA, Dementia Connect, Dementia Roadmap. / The Dementia Roadmap provides high quality information about the dementia journey alongside local information about services. / Home | Dementia Roadmap Dementia Roadmap / Dementia page on practice website
PARTNERSHIPworking with carers, family and friends
Carers support / Consider nominating a Carers champion in the surgery and to join Dignity In Care ( Free).
Identify carers for all patients with dementia by sending them a letter via the patient to ask them to identify themselves.
Code the carers and ensure they are included and invited at all stages of the patient’s journey.
Offer Flu vaccination to all carers.
Refer Carers to local Carers UK for resources and support.
Consider referring Carer to the local Dementia Advisor (DA) for help to manage their cared for with dementia. / Dignity in Care
Dignity In Care resources; Dignity in care - Helpful resources
Consider Dignity in Care training
Carers UK Local Directory Search - Carers UK / A Carers Champion identified
95% of those on the register have a Named significant person/carer.
100% of known carers to be coded
95% should be offered Flu Vaccination
SPACE principles / Potential Ideas for
Action Plan / Resources / Outcomes
Patient and Public Involvement / Involve the practice Patient Participation Group (PPG) in this work and ask patients with dementia
and their carers what they feel will make the surgery dementia friendly.
Consider PPG running an engagement event for dementia and or carers
PPG to consider running a Dementia Friends session for patients
Involvement in Dementia Research discussed with patients and carers. / Dementia Friends
/ Involvement in Dementia research discussed with 90 % patients and carers
Pharmacy Liaison / Partnership working with the pharmacy; inform your local pharmacist of patients identified with dementia to ensure compliance, consider dosette boxes etc. / Pharmacist involved to perform Medication reviews on compliance – 80% of patients
Working with Fire Service / Fire service can offer home assessment regarding smoke alarms, trip hazards etc. / Home Fire Safety Checks « UK Fire Service Resources / 50% of patients to have been offered home safety check
Befriending Service / Consider befrienders for patients who live alone. / Search Results -- Befriending Networks
SPACE principles / Potential Ideas for
Action Plan / Resources / Outcomes
Working with secondary Care and Other Agencies / Highlight in letters to secondary care/agencies etc. that the patient has dementia and outlining communication/cognitie issues, including main carer contacts.
Safety and telecare / Offer telecare assessment - pendant alarms, key safes etc.
Message in a Bottle - relevant information regarding your medical history and medication is kept within a plastic and placed in a specific place within your home eg your refrigerator so if emergency services are called they know where to access the bottle and the information. / Telecare services
Message in a Bottle; Contact Local Social Services.
Dementia Awareness Event for patients/public / Consider local Alzheimer’s Society /Age UK holding an event in the surgery for patients
Consider PPG running an engagement event
Consider identifying Patient Champions
SPACE principles / Potential Ideas for
Action Plan / Resources / Outcomes
Apply for community recognition/integration / Working towards becoming Dementia Friendly- DAA.
Share plans on the Dementia Action Alliance website.
Consider applying for “Safe Place” status.
Work with Dementia Friendly Community Initiatives. / Dementia Action Alliance;
Safe Place scheme
Safe Places - Keep Safe with Safe Places / Practice should have Action Plan published on the DAA website, and record the progress of the actions
Driving / To inform the DVLA ( NB may still be able to drive
unless advised cognitively seriously impaired)
Consider alternative travel options
Consider Driving Assessments. / Contact, local district and county councils for alternative travel resources;
E.g. Dial a Ride; Concessionary Bus Passes/taxi fares;
Also contact them to identify local Driving Assessment schemes
/ 90% of patients have recoded in their notes that driving has been discussed.
ASSESSMENTand early identification of Dementia.
Increasing early identification of dementia / Sign up to the national Dementia Enhanced Service.
Consider pro-active screening at LTC reviews of patients at risk e.g. 75 yrs.
Patients in Care Homes (60-70% of residents have dementia).
Housebound patients, Patients with vascular long term condition e.g. heart disease, stroke disease, Parkinson’s, neurological disease, Patients with memory loss. / NHSE; Dementia diagnosis and management; A brief pragmatic resource for general practitioners-
Sign up to the DES
Consider targeted memory screening;
- MCI
- Delirium
- Patients in Care Homes
- Patients over 90 years old, then 80 years old etc.
- Housebound patients
- Patients with vascular LTC; stroke , diabetes, IHD
- Patients with neurological LTC; Parkinsons, epilepsy.
Practice to be signed up to the Enhanced Service; Facilitating timely Diagnosis with Dementia.
SPACE principles / Potential Ideas for
Action Plan / Resources / Outcomes
Data Harmonisation / Review of patients at risk /with Memory Cognitive Impairment, patients on acetyl-cholinesterase’s / Coding: It has been identified that there are a number of codes which may indicate a diagnosis of dementia but are not picked up by QOF. Therefore, by running a search to highlight patients with dementia-related codes without a diagnosis of dementia, practices may be able to increase diagnosis rates.
Data Harmonisation Toolkit includes searches for SystmOne, EMIS Web, Microtest and InPS Vision –
A list of the read codes captured by QOF can be found in Appendix 2 of the document (a list of those codes not picked up can be found in Appendix 3). / Practice completed annual data harmonisation
Screening in the Housebound / Consider Dementia Advisors/ Carers Support/District Nurses to conduct memory screening ( depends on local pathway)
Reduce use of anti-psychotic medicines in patients with dementia.
Reduce use of anticholinergics in patients with dementia or memory cognitive impairment. / Consider an audit. / Contact CCG Meds Management team for further advice and guidance / Full audit cycle completed
SPACE principles / Potential Ideas for
Action Plan / Resources / Outcomes
CARE PLANS which are person centred.
Physical Health / Consider managing patient’s cardiovascular risks annually- BP, pulse, smoking, ETOH status, encouraging exercise, hydration and good diet. Also ask about hearing and vision and encourage assessments if appropriate / Person Centred Care To consider a Year Of Care ; Care Planning Approach for dementia NHS Year of Care
/ 95% of patients to have had an annual review; to include;
1.Health /LTC review
2.Social review,
3.Medication review
4.Carers review
Care Plans / Consider families/patients complete a This Is Me document and hold copy on patients notes (to be enclosed with referrals to other agencies). / / 95% of patients to have a This is Me document.
60% to have completed and with patient clinical record
Planning for the future / Encourage Power of Attorney conversations, advanced care plans, wills.
Consider early conversations around EoL; preferred place of care/death and DNR status /
End of Life planning in Dementia;
Advanced Care Planning in Dementia
/ 95% of patients to have had a discussion about the future at their annual review
SPACE principles / Potential Ideas for
Action Plan / Resources / Outcomes
Planning for the present / Consider each patient with Dementia at a multi-disciplinary meeting.
Consider sharing a plan for each patient on the Shared Care Platform ( as used for the Avoiding Admissions DES) / Consider regular meetings with a MDT to discuss patients on the register ( similar to Gold Standards Meeting) suggested attendees; GP, Practice Nurse, Dementia Champion, Local Carers support rep, District Nurse, Dementia Advisor/ CPN, social worker, pharmacist.
To produce a Care Plan as required for the Avoiding Unplanned Admissions DES and publish on the shared care platform.
/ Quarterly meetings with action plans and minutes /reports
85% to have a shared Care Plan on platform
Appointment management / Flag patient notes with an “alert” to offer a double appointment if appropriate
Encourage patients to bring a carer/friend to appointment
To send text/phone patient prior to appointment
If patient’s DNAs, to proactively rebook an appointment / 85% of patients to have notes “flagged”
100% of patients to have named clinician ( GP or Nurse) as key co-ordinator
Post Diagnostic Support Service / Consider referring patients on to dementia ‘post diagnosis support services’ /Dementia Advisors ( NB depends on local commissioned services) / 95% patients made aware of the local Dementia Advisory service
Financial support / Consider advice re council tax rebates, Attendance Allowance, Carers Break funding. / Local County Council Welfare Benefits Team
Benefits Enquiry Helpline for people with disabilities and carers
Tel: 0800 88 22 00
SPACE principles / Potential Ideas for
Action Plan / Resources / Outcomes
Patient/Carer feedback / Consider a patient/carer survey / Friends and family / Survey completed, with a report and action plan.
ENVIRONMENTS that are dementia friendly.
Consider a walk around of the surgery by staff members, patients, carers / Kings Fund toolkit / Audit and toolkit performed by practice
Consider designating a “quiet area” to reduce risk of agitation (inside or outside)
Develop a “memory Box” for the waiting room for use by dementia patients and carers/staff / Memory Box available
Consider making the surgery a safe haven for people who are found wandering in the area
Uncluttered floor space and plain carpets
Clear signage for toilets and exits - use symbols.
Good lighting, sense of calm / Consider; signage, noise, carpets and accessibility, memory clock for orientation.