Dementia Strategy 2019-2021 - "High quality compassionate care that makes a positive difference to our community" - Isle of Wight NHS Trust
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Dementia Strategy
2019-2021
“High quality compassionate care that makes a
positive difference to our community”
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Forward
As a learning organisation we are always looking for Message from Alice Webster,
ways to improve the services that we provide, and Director of Nursing, Midwifery, AHPs and Community:
having a strategy that demonstrates how we will do this “It is really important that we work with people who
is important. People are living longer and often with a have dementia sensitively and in a person centered way
recognising the importance of their personhood and
number of long term conditions, like dementia. who they are. People with dementia still have unique
stories to tell about who they are, what is important
The Isle of Wight’s population is on average older 1. Deliver excellent person centred-care support to them and the lives they have led. Understanding
than the rest of the UK and many more people live for people with dementia and their carers by the importance of this and making it central to skilled,
alone in their later years. The NHS needs to change diagnosing dementia and delirium promptly
compassionate care is essential. It is critical our strategy
to meet the needs of our local community and at the and providing the right support at the right
same time services are under pressure and money is time from diagnosis through to end of life. demonstrates the change we make as to way we work
tight. Our strategy will help us face these things. with people who have dementia and those that love
2. Develop a highly skilled, dementia aware
Dementia is an umbrella term describing a serious workforce that provides compassionate care and care for them.“
deterioration in mental functions, such as memory, and demonstrates confidence in their roles.
language, orientation and judgement which impacts
3. Champion improvements in dementia care
upon the person’s ability to carry out everyday tasks.
at governance, strategic, operational and
The Isle of Wight has a higher than average elderly frontline level in the organisation.
population and people with dementia are on the
4. Create dementia friendly areas with secure,
Message from Marcia Meaning,
increase. We want to be recognised as leaders in
safe, comfortable, social and therapeutic Head of Nursing and Lead for Dementia
dementia friendly care and ensure that our patients
environments that facilitate all types of
with dementia have the best experience possible.
functioning. “There are few of us whose lives have not been
Dementia is a disorder that affects people’s cognitive
abilities, which may also impact on their physical
5. Work in collaboration with partner touched by someone living with dementia; a person
organisations, and volunteers to involve, who has led a rich and fulfilling life and is much loved
health needs, and as such the person may require
support and engage all relevant agencies
support at any time throughout their journey from by family and friends. It is vital that people living with
where appropriate throughout the person’s
diagnosis to end of life. Many people with dementia dementia are provided care that acknowledges their
journey from admission to discharge and or
live well within the community when they are
supported from a range of multi agencies, third
end of life. individuality and is sensitive to their needs, and to also
sector, families and carers. 6. Actively participate in audits to maintain ensure that we provide the best care for those that care
The Isle of Wight Trust has developed this strategy
and improve standards, which will include for and are important to them.
developing data collection and monitoring
and sets out our dementia priorities which are
divided into 6 key themes as follows:
programmes to support and improve Our strategy aligns with the Well Pathway for
dementia, frailty and delirium screening Dementia identifying the need to prevent dementia, to
rates.
diagnose effectively, to provide safe care and support,
These key themes provide the core foundations to to promote living well within communities, and to
which our strategy is developed. The strategy takes
ensure, when the time comes, that individuals die in
a multi-agency approach, which will enable us to
positively support people with dementia and their dignity in a place of their choosing.”
carers during their admission to discharge journey,
to reduce the impact of a hospital admission on
their health and well-being. The implementation and
progress of the key themes identified in this strategy
will be monitored by the Trust Quality Committee.
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Local Context Our services
Dementia is acknowledged as becoming the UK’s largest Isle of Wight NHS Trust is the only integrated acute,
health and social care challenge. There are just under 3000 community, mental health and ambulance health care
people estimated to live with dementia on the Island and provider in England. Established in April 2012, the Trust
due to our elderly population and increasing life expectancy provides a full range of health services to an isolated
the number of people living with dementia is estimated to offshore population of 140,000.
increase to 3651 by 2024. This means that ensuring people
are supported to live well with dementia on the Island is Our services include:
one of our top priorities. Acute Care Services
Based at the heart of the Island and handling 26,636 admissions each year, St Mary’s Hospital in Newport
In 2014, the Isle of Wight NHS Trust, Isle of Wight CCG, Hampshire Constabulary, My Life a Full Life and the is our main base for delivering acute services for the Island’s population. Services include A&E with 46,622
Isle of Wight Council worked collaboratively to produce the Isle of Wight Dementia Strategy 2014-2019. The attendances, the Urgent Care Service (by referral only), emergency medicine and surgery, planned surgery,
key priorities of this were: intensive care, comprehensive maternity, SCBU and paediatric services with 1136 births last year. Within
our Acute services, a number of Planned Care services including chemotherapy and orthopaedics are also
delivered.
• Improve awareness and prevention.
• Ensure people receive a timely diagnosis and appropriate post diagnostic treatment and Community Care Services
support.
Delivered in patients’ homes, in a range of primary and community settings and from St Mary’s Hospital, our
• Create dementia friendly communities.
Community Care services include district nursing, health visiting, community nursing teams, a primary dental
care service and orthotics, as well as inpatient rehabilitation and community post-acute stroke wards with
As part of this strategy, an Isle of Wight Dementia Roadmap was produced over 221,900 patient contacts each year.
The Isle of Wight Dementia Roadmap provides high quality information about the dementia journey
alongside local information about services, support groups and care pathways to assist primary care
Ambulance Services
to support people with dementia and cognitive impairment, their families and carers. It embraces NHS The Island’s ambulance service delivers all emergency and non-emergency ambulance transport for the
England’s Well Pathway for Dementia’s key areas of focus, which are given in detail on page ??: Island’s population. The service responds to 28,915 emergency calls and 70,873 non-emergency calls to NHS
111 each year on average. The service is also responsible for transporting patients to mainland hospitals
The table below clearly demonstrates the increasing trend in both estimates and diagnosis:
when required.
4000
Mental Health Services
3500
Mental Health services provide inpatient & community based mental health care receiving over 6,000
3000
referrals to the service. Our portfolio also includes community CAMHS, Early Intervention in Psychosis,
2500 Memory Service and intensive outreach service for residential and nursing care homes. The service also
provides learning disability community services.
2000 Diagnosed
1500 Estimated
1000
500
0
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Summary Vision The Well Pathway
Our Trust-wide vision is for high quality, compassionate care NHS England Transformational Framework developed the
that makes a positive difference to our Island community. Well Pathway for Dementia as part of the Prime Minister’s
Putting this in the context of dementia, we will identify Challenge on Dementia 2020.
patients living with dementia and ensure we spend time This was designed to ensure that patients have a better experience of health and social care support from
getting to know their preferences, working with them on diagnosis through to end of life. The ‘well pathway ‘ sets an overarching framework to align and co-ordinate
the contribution of health and social care partners to meet our key commitments, and is broken down into
activities they can enjoy in order to minimise the fear and the following domains:
disruption of being in hospital. Preventing well - Ensuring that the risk of people developing dementia is minimised
Diagnosing well - Timely, accurate diagnosis, care plan and review within the first year
In order to do this we will create a prepared and able
Supporting well - Access to safe, high quality health and social care for people with dementia and their
workforce that is ready to care for our patients in an carers both in the acute hospital and community
appropriate manner and setting. Living well - People with dementia can live normally in safe and accepting communities
Dying well - People living with dementia die with dignity in the place of their choosing
In order to facilitate delivery of the Well Pathway, below are details of how this will be managed locally.
1. Preventing well
Deliver excellent person centred-care support for people with dementia and their carers by diagnosing
dementia and delirium promptly and providing the right support at the right time from diagnosis through to
end of life.
• We will improve the care of people with dementia to maintain their quality of life and support
the development of a dementia pathway from diagnosis to end of life, which reflects a
coordinated approach of health and social care professionals, families, people with dementia
and the third sector, and
• Accurately diagnose dementia and delirium in a timely manner.
• Have this evidence based pathway that reflects the needs of people with dementia
We will achieve this by
• Undertaking a review of all our acute wards and departments using the NHS England
The Well Pathway for Dementia within the Trust, (based on the NICE guidelines) and
implement this evidence based practice pathway.
• Ensure that staff and volunteers have the knowledge and skills to support people with
dementia to engage in meaningful activities whilst on the wards.
• Introduce a dementia care outreach team in our community, which will enable
professionals to identify signs of delirium, dementia and mental health deterioration and
proactively act on these.
|6 7|2. Diagnosing well 4. Living Well
Work in collaboration with partner organisations, and volunteers to involve, support and engage all relevant Develop a highly skilled, dementia aware workforce that provides compassionate care and demonstrates
agencies where appropriate throughout the person’s journey from admission to discharge and or end of life. confidence in their roles.
• Our aim is to provide the best clinical outcomes within dementia across all the services that we • We want to have a workforce throughout our hospital that has dementia care training based
provide. We will focus on what good looks like, and the way in which things will be done by on their roles and responsibilities. This will enable them to meet the needs of people with
implementing evidence based practice in conjunction with our partner agencies. dementia whilst ensuring they are skilled and competent to deliver the care required in a timely
manner.
Actively participate in audits to maintain and improve standards, which will include developing data
collection and monitoring programmes to support and improve dementia, frailty and delirium screening Champion improvements in dementia care at governance, strategic, operational and frontline level in the
rates. organisation.
• We want to create and maintain high standards of care for people with dementia in our • We will ensure that all people with dementia who use our services are located in the most
organisation with a key focus on achieving, delivering and maintaining excellent clinical care appropriate place from admission to discharge.
through participating in audits and developing monitoring programmes which measure the
experiences of the person’s journey within acute care. • All people with dementia will be supported by staff at all levels of our organisation and this
will be led by our specialist champions, who will ensure that each area is provided with
• Work with key stakeholders to design a multidisciplinary team for the delivery of acute support support at the earliest opportunity.
for people with dementia.
• We will minimise the number of ward moves patients living with a diagnosis of dementia
experience. We will not move patients with a dementia diagnosis in the out of hours period
unless it is clinically necessary for their care and treatment.
3. Supporting well
Create dementia friendly areas with secure, safe, comfortable, social and therapeutic environments that
facilitate all types of functioning. We will achieve this by:
• We want to create environments that provide a more positive experience for people with • Introduce medical and nursing champions for deterioration, which will focus on
dementia who use our acute services and support their families and carers, with a key focus on identification, implementation, monitoring and evaluation of the deteriorating person
achieving, delivering and maintaining an environment that enables and not disadvantages the with dementia. The will attend the Dementia Lead’s meetings, and will assist with the
patient. implementation of the Butterfly Scheme.
• We will develop a culture where people with dementia’s nutritional needs are a priority,
recognising the challenges faced by them as a result of the impact dementia can have on
We will achieve this by eating and drinking.
• Working closely with the Patient Experience and Estates Teams to ensure that the needs • A policy will be written on Assessment and Management of Behavioural and
of people with dementia are met, ensuring that dementia friendly environments as one Psychological Symptoms of Dementia.
of the key priorities for the Estate strategy.
• Ensure that the person‘s discharge planning is commenced on the day of admission to
prevent any unnecessary delays in discharge.
5. Dying well
• Ensure that people with dementia are discharged directly from their wards and not
• Work with our Integrated Palliative and End of Life Care Team (IPET) to support in providing
transferred to the discharge lounge.
high quality care in line with our Trust’s End of Life Care Strategy.
• Establish staff, patient and carer experience and engagement forums through our
dementia champions who will support with regular auditing and monitoring of dementia
environment.
• Offer people with dementia and their carers Friends and Family Test and carer surveys..
• Review and implement any recommendations from patient and carers comments through
our Friends & Family Test, information from PALS and our complaints department. Ensure
Johns Campaign is used to monitor the input of carers for people with dementia.
• Reintroduce Alzheimer’s Cafes which have been postponed due to Covid-19
|8 9|Enablers Delivery Plan
To achieve the requirements of the Well Pathway it is Well pathway Detail Delivery date
recognised the Trust needs to work on some key enablers Preventing well Develop an evidence based dementia pathway
October 2020
outlined in the table below Ensuring that the risk of people
which reflects a coordinated approach
developing dementia is minimised Introduce a dementia outreach team August 2020
Leadership Identify a key lead for Dementia care within the Trust strategically and Diagnosing well Accurately diagnose dementia and delirium in a
operationally. December 2020
timely manner
Ensure the leadership for Dementia care is visible and accessible. Timely, accurate diagnosis, care
plan and review within the first
Establish a clear patient pathway for Dementia patients that use NHS services. Regularly undertake audits to monitor progress September 2020
year
Develop a local training and development plan that will meet the needs of
Supporting well Introduce more dementia friendly environments March 2021
staff delivering Dementia care in the Trust.
Develop a clear communication plan for Dementia care in the Trust. Access to safe, high quality Ensure discharge planning is commenced on
September 2020
health and social care for people the day of admission
Service Structure Put in place dementia Champions to lead and deliver this important aspect of with dementia and their carers
patient care. Ensure no Patients with dementia are
October 2020
discharged via the Discharge Lounge
All staff in Dementia roles will have an up to date job description.
Establish a robust Dementia Steering Group to have oversight of Dementia Introduce patient, carer and staff engagement
March 2021
care in the Trust. forums through Dementia Champions
Governance Develop a clear structure of governance so that Dementia reports into Offer people with dementia and their carers the
September 2020
and Reporting operational forums and links to Trust Board. opportunity to provide feedback
The formal minutes of the monthly Dementia Steering Group will feed into the Living well Ensure all relevant staff have completed
March 2021
Trust Quality Committee on a monthly basis. Dementia awareness training
People with dementia can live
Planned reports to go to Trust Board on a quarterly basis. normally in safe and accepting Roll out the butterfly symbol and monitor its
August 2020
Dementia care is a core improvement area in the Trust Quality Strategy. communities use
Collect activity and performance data for Dementia care within the Trust. Ensure all patients with dementia have a “This
November 2020
Is Me” document completed
Partnership Working Be an active member of the Isle of Wight Strategic Dementia Group.
Produce a policy on managing behaviours that
Documentation and Embed the use of the “This is Me” document into all Trust services for November 2020
patients with Dementia. challenge
Record Keeping
Dying well
Auditing Develop a local audit plan for Dementia. Work with IPET to ensure there is high quality
Participate in the National Audit of Dementia. People living with dementia die care in death that meets the patients personal September 2020
with dignity in the place of their requests where possible
Use local data (patient feedback, incidents and complaints) to drive forward choosing
positive changes that are patient focused.
Undertake a self-assessment of the Trust against the well pathway now and
after the implementation of this strategy.
IT Use technology to ensure timely access to information and advice on
Dementia care within the Trust.
Ensure local online information systems are fit for purpose and patient focused
with the aim of sharing information about patients in a timely manner that
will enhance decisions and care for patients living with Dementia.
Develop an Intranet page for Dementia.
Patient Engagement Engage patients and carers with the local Dementia Champions meetings.
Engage with patients on social medial to gain feedback and ideas about
Dementia care.
Provide regular updates to Patient’s Council.
| 10 11 |Accountability and Measuring success and
Responsibility evaluation
Delivery of the strategy will be overseen by the Progress towards delivering the strategy objectives
Director of Nursing and the Dementia Lead Nurse. will be measured through the Dementia Steering
The Dementia Steering group will report to the Group. The gap analysis with regard to this
Quality Committee on a quarterly basis, which strategy has been undertaken as part of the local
reports to Trust Board. improvement plan for Dementia care, utilising both
national and local documents for completeness. The
The Dementia Steering Group will take responsibility delivery and measures for this will be captured via
for implementation of the Strategy’s objectives, for this plan and within the Dementia Steering Group.
setting out the methods of implementation and
measuring progress.
Contact
The clinical Divisions and Care Groups are
responsible for embedding the strategy at local If you would like to discuss this strategy further,
level and having a clear action plan on the delivery please contact Marcia Meaning, Lead for Dementia
of Dementia care in their respective areas – acute, via marcia.meaning@nhs.net
mental health, community and ambulance. The
Dementia Lead Nurse will ensure the Care Group
action plans are aligned with the overarching
improvement plan for Dementia care within the
Trust. The clinical divisions are also responsible for
delivering the strategic goals at an operational level,
with support from the Dementia Lead Nurse and the
Steering Group.
Communication
The Dementia Strategy will be circulated to all
members of the Trust Board, Care Group Directors,
Heads of Service, Heads of Nursing, Matrons,
Ward Sisters and Service Leads for dissemination
to all clinical staff. A copy will also be circulated to
key partner organisations and stakeholders. The
Dementia Strategy will be available to view and
download on the Trust website. It will be accessible
to patients, carers and staff.You can also read
