Appendix one -draft dementia strategy action planPrint page

Version 5 – last updated 9 December 2016

This action plan is owned by South Gloucestershire Council (SGC) and South Gloucestershire Clinical Commissioning Group (CCG). Reports on progress are made to the Dementia Planning Group.

1. Increase awareness and understanding of dementia amongst professionals and the public

	OBJECTIVE	WHAT WILL WE DO	WHO WILL DO IT	BY WHEN
1.1	Increase awareness of dementia and reduce stigma	1.1.1 Grow SGDAA work to increase awareness, reduce stigma & build community support.	Winsome Barret-Muir – Southern Brooks	Until August 17
		1.1.2 Increase the number of Dementia Friends in South Glos.	Winsome Barret-Muir – Southern Brooks	Ongoing
		1.1.3 Roll out Dementia Friends for people with learning difficulties	Winsome Barret-Muir – Southern Brooks	December 2017
		1.1.4 Continue working with BME communities to raise awareness	Winsome Barret-Muir – Southern Brooks	Until August 17
		1.1.5 Continue Roadshows and Dementia Guide to Services.	Paul Frisby – CCG Sue Jaques – SGC	Ongoing
		1.1.6 Work towards accrediting GP practices as carer and dementia friendly.	Paul Frisby – CCG Fiona O’Driscoll – SGC	June 2018
		1.1.7 Develop message about the positive aspects of getting a dementia diagnosis.	All	Ongoing
		1.1.8 Raise awareness of dementia amongst businesses to support customers with dementia and large employers to support employees with dementia to continue working	Winsome Barret-Muir – Southern Brooks	Until August 17
1.2	Encourage and promote the value of healthy lifestyles	1.2.1 Continue SGC initiatives to encourage everyone to be active and healthy.	Sarah Weld – SGC	Ongoing
		1.2.2 Build on national One You Public Health initiative	Sarah Weld – SGC Paul Frisby -CCG	Ongoing
		1.2.3 Health and care staff promote healthy lifestyles.	Sarah Weld – SGC Paul Frisby -CCG	Ongoing
1.3	Connect people with dementia with their friends and communities.	1.3.1 Community Connectors improving opportunities for all vulnerable adults.	Robin Woodward – Curo	Until March 18

2. Improve diagnosis rates and ensure a timely diagnosis for those with dementia.

	OBJECTIVE	WHAT WILL WE DO	WHO WILL DO IT	BY WHEN
2.1	Continue to improve dementia diagnosis and assessment	2.1.1 Build on GP knowledge base and support them to provide timely assessment and diagnosis.	Peter Bagshaw & Paul Frisby – CCG	Ongoing
		2.1.2 Demonstrate referral to treatment times for people with cognition concerns are within 18 weeks.	Peter Bagshaw & Paul Frisby – CCG	Ongoing
		2.1.3 Create self-referral pathway for people with young on set dementia and those with memory concerns.	Peter Bagshaw & Paul Frisby – CCG Grace Mawson – AWP	December 2018
		2.1.4 Investigate screening people of dementia as part of regular health checks.	Paul Frisby – CCG Sarah Weld – SGC	June 2017
		2.1.5 Develop and publish a dementia pathway (BNSSG) for people and professionals to use	Dementia Planning Group	December 2017
		2.1.6 Support GP’s with clear guidance on how to recognise less common forms of dementia to refer to specialists	Paul Frisby – CCG Grace Mawson – AWP Judy Haworth – NBT	June 2018
		2.1.7 Review the diagnostic assessments used in primary and secondary care and whether they are culturally appropriate for BAME groups.	Peter Bagshaw & Paul Frisby – CCG Grace Mawson – AWP	December 2018
		2.1.8 Regular screening and health checks for people with learning difficulties	Emily Denham – Sirona	Ongoing
		2.1.9 Investigate a self-referral pathway for people worried about memory loss	Peter Bagshaw & Paul Frisby – CCG Grace Mawson – AWP	December 2018
		2.1.10 Continue to ensure undiagnosed cognitive impairment in secondary care is investigated.	Judy Haworth – NBT Paul Frisby – CCG	Ongoing
		2.1.11 All partners to ensure people with cognition concerns are offered screening by GP	All	Ongoing
2.2	Improve support for people at risk of developing dementia	2.2.1 Investigate support and monitoring of people diagnosed with mild cognitive impairment.	Peter Bagshaw & Paul Frisby – CCG	March 2019

3. Ensure high quality information about dementia, local services and support is available to all those with a dementia diagnosis and their carers

	OBJECTIVE	WHAT WILL WE DO	WHO WILL DO IT	BY WHEN
3.1	Ensure the staff are trained to recognise and support people with dementia.	3.1.1 Continue specialist dementia training for staff working with people with learning difficulties.	Sue Parris/Emily Denham – Sirona	Ongoing
		3.1.2 Increase dementia awareness for care home staff.	Care Home Liaison – AWP	December 2017
		3.1.3 Promote participation in research for individuals and professionals	Paul Frisby – CCG Sue Jaques – SGC	Ongoing
		3.1.4 Understand the links between sight loss and dementia and ensure appropriate information and support is available.	Paul Frisby – CCG Sue Jaques – SGC	December 2018
3.2	Generic transferable dementia training across the sector	3.2.1 Develop generic dementia training	Dementia HIT Partnership Judy Haworth – NBT	December 2020
3.3	Ensure people with learning difficulties are assessed and supported appropriately.	3.3.1 Continue to work in partnership to assess and support people with a learning difficulty and dementia diagnosis.	Sue Parris/Emily Denham – Sirona	Ongoing
		3.3.2 Maintain a comprehensive library of information about joint diagnosis of dementia and learning difficulties.	Sue Parris/Emily Denham – Sirona	Ongoing
		3.3.3 Continue to develop specialist training to support people with dementia and a learning difficulty living in a care home or support living.	Sue Parris/Emily Denham – Sirona	Ongoing
3.4.	Support people with dementia throughout the progression of the disease.	3.4.1 Submit Dementia Advisors proposal to build on this year’s pilot to provide a named contact, support and signposting to other services and support people nearing crisis.	Paul Frisby – CCG Sue Parris – Sirona Lorna Robertson – Alz Soc	Current service until June 2017
		3.4.2 Encourage partnerships between carers, health, social care and voluntary sector to support people with dementia.	Sue Jaques- SGC Paul Frisby – CCG	Ongoing
		3.4.3 Continue to offer the ‘Real Life with Dementia’ course.	Beth Tovey – SGC Paul Frisby – CCG	Ongoing
		3.4.4 Ensure post diagnostic courses are offered to everyone with a diagnosis.	Paul Frisby- CCG Grace Mawson – AWP	Ongoing
		3.4.5 Encourage individuals to access psychological support.	Paul Frisby – CCG Rowena Hastings – CCG	Ongoing
		3.4.6 Maintain a range of community activities for people with dementia and their carers	Paul Frisby- CCG Sue Jaques – SGC Lorna Roberston – Alz Soc	Ongoing
		3.4.7 Investigate advocacy and develop provision for people with dementia.	Paul Frisby – CCG Sue Jaques – SGC	Ongoing
		3.4.8 Investigate developing dementia specialists in each team, health and care setting.	Paul Frisby – CCG Sue Jaques – SGC	December 2019
		3.4.9 Ensure that services and support are sensitive to sexual orientation and trans people, both the person with dementia and their carer.	Paul Frisby – CCG Sue Jaques – SGC	December 2019
		3.4.10 Services to collaborate to ensure a dementia diagnosis is shared (the people may not)	All	Ongoing
		3.4.11 Understand the issues for people that live alone with dementia and communities that support them.	Paul Frisby – CCG Sue Jaques – SGC	December 2017
3.5	Support people with young onset dementia	3.5.1 Investigate different support for younger people with dementia.	Paul Frisby – CCG Sue Jaques – SGC	December 2019

4. Develop care and support to meet the needs of individuals with dementia and their families and other carers, to maintain independence and avoid crisis.

	OBJECTIVE	WHAT WILL WE DO	WHO WILL DO IT	BY WHEN
4.1	Support to manage behaviours that challenge.	4.1.1 Support before or at crisis to enable people with dementia to stay at home, or as close to that as possible.	Paul Frisby – CCG Sue Jaques – SGC Rowena Hastings – AWP Lorna Robertson – Alz Soc Sue Parris – Sirona	December 2017
4.2	Holistic long term care for people with dementia.	4.2.1 Integrated community services to offer people with dementia and other LTCs more holistic care.	Paul Frisby – CCG Sue Jacques – SGC Parris – Sirona	June 2018
		4.2.2 Access for all people with dementia to a wide range of therapies and other meaningful activities.	Paul Frisby – CCG Rowena Hastings – AWP Sue Jaques- SGC Lorna Robertson – Alz Soc Sue Parris – Sirona	June 2018
		4.2.3 Constructive and pragmatic care plans that are used by professionals and individual that take account of all of the equalities groups.	Paul Frisby – CCG Sue Jaques – SGC Sue Parris – Sirona	Ongoing
		4.2.4 Ensure that people with dementia are able to maintain good dental health.	Sarah Weld – SGC Paul Frisby – CCG	June 2018
		4.2.5 Review the need for a crisis response team that operates outside of normal working hours.	Paul Frisby – CCG Sue Jaques – SGC	June 2018

5. Recognise the contribution of carers, and encourage and enable them to look after their own health and wellbeing as well as those they care for.

	OBJECTIVE	WHAT WILL WE DO	WHO WILL DO IT	BY WHEN
5.1	Support carers of people with dementia well.	5.1.1 All people with diagnosis and their main carer are offered place on post diagnosis course.	Grace Mawson – AWP Paul Frisby – CCG Sue Parris – Sirona	December 2017
		5.1.2 All people with dementia and their carers have a support plan including advance care planning.	Paul Frisby – CCG Grace Mawson – AWP Sue Parris – Sirona	December 2017
		5.1.3 Work to ensure carers training continues and is supported by (Council/ CMHT, Alzheimer’s Society, Carers Support Centre)	Paul Frisby – CCG Sue Jaques – SGC Lorna Robinson – Alz Soc Keith Sinclair – CSC	Ongoing
		5.1.4 Investigate annual checks & medication reviews for people with dementia	Paul Frisby – CCG	December 2017
		5.1.5 Use technology early in diagnosis whilst person has capacity and improve quality of life & use technology to support people with dementia	Sue Jaques – SGC	June 2017
		5.1.6 Work with people with dementia and carers encouraged them to remain in control.	Paul Frisby – CCG	Ongoing
		5.1.7 Investigate buddying and other types of support for people that cannot or do not want to join groups.	Paul Frisby – CCG Sue Jaques – SGC	Ongoing
		5.1.8 Supported families to understand the difference between neglect and disease management in end of life complex cases.	Sue Parris – Sirona Paul Frisby – CCG Sue Jaques – SGC	December 2019

6. Improve provision for people who can no longer live at home, supporting care homes to meet the needs of people with dementia and developing alternatives.

	OBJECTIVE	WHAT WILL WE DO	WHO WILL DO IT	BY WHEN
6.1	Support to manage behaviours that challenge	6.1.1 Care Home Liaison support homes to manage individuals they find challenging and deliver tailored training.	Paul Frisby – CCG Sue Jaques – SGC Rowena Hastings – AWP	December 2017
6.1	Support to manage behaviours that challenge	6.1.2 Care homes offered time limited support to enable them to continue caring for people with behaviour they find challenging.	Paul Frisby – CCG Sue Jaques – SGC Rowena Hasting –AWP	December 2017
6.2	Increase and diversify the types of care available for people with dementia.	6.2.1 Develop alternatives to care home placements eg Shared Lives.	Paul Frisby – CCG Sue Jaques – SGC	December 2019
		6.2.2 Increase nursing home placements for people with dementia.	Sue Jaques – SGC	December 2019
		6.2.3 Specialist extra care for people with dementia.	Sue Jaques – SGC	December 2019
		6.2.4 Ensure reablement services are accessible to people with dementia.	Sue Jaques – SGC	December 2017
		6.2.5 Continue to develop capacity for dementia nursing beds in care homes	Paul Frisby – CCG Sue Jaques – SGC	Ongoing
6.3	Investigate establishing a dementia care hub in South Gloucestershire	6.3.1 Ensure co-ordinated care through establishing a dementia ‘hub’.	Paul Frisby – CCG Sue Jaques – SGC	December 2019
6.4	Work with care homes to continue improve quality	6.4.1 Continue to improve training in care homes	Paul Frisby – CCG Sue Jaques – SGC	Ongoing
6.4	Work with care homes to continue improve quality	6.4.2 Explore introducing a Care Home Quality Mark	Paul Frisby – CCG Angela Marsh – SGC Care Home Partnership	June 2019

7. High quality hospital care for people with dementia, including pathways to ensure appropriate and timely discharge.

	OBJECTIVE	WHAT WILL WE DO	WHO WILL DO IT	BY WHEN
7.1	Continually improve quality of dementia care in local hospitals	7.1 Work with hospitals to continue improving quality	Judy Haworth – NBT	Ongoing
7.2	Reduce length of stay in hospital for people with dementia.	7.2 Investigate the feasibility of discharge to assess for people with dementia.	Paul Frisby – CCG Sue Jaques – SGC
7.3	A memory Café at Southmead Hospital	7.3 Develop Southmead Hospital Memory Café.	Judy Haworth – NBT Jet O’Neill – AWP Lorna Robertson – Alz Soc	June 2017
7.4	Improve access to and discharge from Callington Road Hospital.	7.4.1 Introduce protocol and operational standards for Callington Road later life wards.	Jane Salmon – AWP Paul Frisby – CCG Kenny Braidwood – SGC	September 2017
		7.4.2 Consider provision of desks and IT links to enable social workers to spend more time at Callington Rd.	Paul Frisby – CCG Sue Jaques – SGC Jane Salmon- AWP	September 2017
		7.4.3 Publicise Laurel ward –criteria for admission.	Jane Salmon – AWP Paul Frisby – CCG Kenny Braidwood – SGC	September 2017
		7.4.4 Introduce discharge to assess for Laurel Ward	Paul Frisby- CCG Sue Jaques – SGC	September 2017

8. High quality end of life care

	OBJECTIVE	WHAT WILL WE DO	WHO WILL DO IT	BY WHEN
8.1	People with dementia have advance care and support plans for end of life	8.1.1 Advance support and care planning offered to all people with dementia and their carers.	All Dementia planning group	Ongoing
8.1		8.1.2 Ensure that people with learning disabilities and dementia are enabled to develop advance support and care planning.	Emily Denham – Sirona	Ongoing
8.2	People with learning difficulties and dementia have advance care and support plans.	8.2.1 Ensure Sirona End of Life Co-ordination Centre meet the needs of people with dementia.	Sue Parris – Sirona	Ongoing
8.3	Bereavement support for carers of people with dementia after they die.	8.3.1 Investigate Bereavement support for carers of people with dementia after they die, as with CLDT.	Paul Frisby – CCG	June 2018
8.4	Focus should be quality of life not length of life	8.4.1 All partners to have honest and open conversation with people with dementia and their carers	All	Ongoing