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North Somerset Community Partnership

North Somerset Community Partnership is a Community Interest Company that provides healthcare services on behalf of the NHS to the people of North Somerset. Our priority is to help the people we care for stay well, and help those that need treatment recover in the best place for their needs. Our values are quality, respect, effectiveness, integrity and partnership, these are integral to everything we do to ensure we are delivering the best quality services. We are committed to involving staff in decision making and all permanent staff are invited to be shareholders. As a Social Enterprise, our vision is to provide social value through quality health services for the community. Our duty is to invest any surpluses we generate to improve the health of the North Somerset community. Our services are delivered by a wide range of nursing, therapy and other professional staff.

30 October 2016
South West
Health, Care, Hospitals and Hospital Trusts
Local Alliances:
North Somerset Dementia Action Alliance, Portishead Dementia Action Alliance

1. Action Plan

1. The National Dementia Declaration lists seven outcomes that the DAA are seeking to achieve for people with dementia and their carers. How would you describe your organisation’s role in delivering better outcomes for people with dementia and their carers?

We wish to become a dementia friendly organisation.

NSCP provides community based services on behalf of the NHS for the people of North Somerset. Our priority is to help all people stay well and when necessary, receive treatment in the best place, often at home or nearby. Our services support people of all ages from early childhood so we are well placed to support the desired outcomes described by people with dementia and their carers in the National Dementia Declaration, the National Dementia Strategy and the mulit-agency North Somerset Dementia Strategy.

Our staff may be the first point of contact with health services for some people.

NSCP staff are in a position to involve people in decisions about their care, support people to live in the place of their choosing and alert other professionals when their involvement might be helpful. They can also give help in getting help for carers, families and friends, help people plan for the future and when the time comes, ensure that people are treated with dignity and respect at the end of life, free of pain and fear.

Our staff will inspire hope for the future by showing, through their actions, that they believe all people are valuable members of the community, regardless of illness or disability and can live well with dementia, thereby being role models in changing perceptions of dementia and the stigma attached to it.

2. What are the challenges to delivering these outcomes from the perspective of your organisation?

The challenges are twofold.


Balancing our vision to provide first class services that go above and beyond expectations, with the national financial squeeze, means we ask more of staff who already have challenging workloads.


There is still a stigma and fear of dementia. Health services have traditionally been illness/cure focused, not person centred or challenged stigma associated with life limiting conditions. Dementia is a condition that will touch the lives of many people and this will increasingly be the case in the future. The challenge is in educating all people into understanding that people with dementia, their carers, families and friends can still live meaningful lives despite the presence of dementia. Also, that a person with dementia can still contribute to the world, their communities, decisions about their care and their future. And that carers make a unique and exhausting contribution and must be listened to and do not want to be pushed from pillar to post when seeking help and support.

Member website


2. Actions

  • NSCP will challenge the stigma associated with dementia amongst NSCP staff and the wider community.

    Dementia awareness education and development will focus not just on loss of abilities and medical management of ‘problems’ but on recognising personal resources, life histories, personhood and abilities of people with dementia.  Values and attitudes towards people with dementia and their carers will be a focus. This may be delivered for some staff groups through linking with the Dementia Action Alliance and the Prime Ministers Challenge to create Dementia Friends and Dementia Champions.

    There will be a strong message that carers are going through a difficult physical, emotional and financial time and staff must learn to recognise them as carers and engage with them as partners in care. Processes will be developed with partner organisations to ensure all carers we have contact with are offered opportunities to maintain their own well-being.

    There will also be an emphasis on seeing the person with dementia as part of a family group and not as the isolated sick person within the family.  A ‘Think Family’ model will be promoted.

    All staff within the organisation will be expected to have received education at this most fundamental level and for the values to be put into practice as part of our core business model.

    Further development opportunities will be made available to staff who have increased clinical involvement, with learning tailored to meet the particular needs of the group of people they work with.

    This will support Outcomes 1, 2, 3, 4, 5 and 6 of the National Dementia Declaration and Objectives  1, 2, 3, 4, 6,7 and 13 of the National Dementia Strategy.


    2016 - Second Quarter Update

    NSCP is therefore exceeded the training targets by over 85% of clinical staff having received Dementia next steps training face to face workshop

    As a consequence of people attending clinical induction and team requests to run this session over the last 12 months an additional 150 staff have become Dementia Friends for NSCP.

    Specialist Dementia training: 10% (75) of clinical staff achieving specialist knowledge. These sessions have been completed and NSCP have trained as at 75 staff in behaviours that challenge, GP diagnosis and pharmacology.

    2015 - Third Quarter Update

    Through the work of making Clevedon Community Hospital dementia friendly and working closely with local Dementia Action Alliances BBC Radio Bristol aired a local piece on dementia awareness raising and action. Dementia lead has started to develop working relationships with local NHS organisations (Avon Wiltshire Partnership NHS Trust) and voluntary organisations (Alzheimer’s Society, Crossroads and Healthwatch).

    We are working with North Somerset Dementia Action Alliances to promote and engage people, volunteers and staff to become dementia friends

    NSCP is reporting in November 2015: • Dementia Awareness: Step 1 is reporting 95% against target of 85% by March 2016. The people attending this training on NSCP induction have also become Dementia Friends • Dementia Next Steps: Step 2 is reporting 85% against target of 75% by March 2016. • Specialist Dementia training: 10% (75) of clinical staff achieving specialist knowledge. These sessions have been agreed and NSCP have trained as at November 2015 40 staff in behaviours that challenge and pharmacology As a community that wishes to be recognised as being dementia-friendly and as NSCP have successfully registered with the official Dementia Friendly Communities recognition process; we will be deemed to be ‘working to become dementia friendly’ and may use the Working to become Dementia Friendly Symbol (‘the symbol’) as long as it remains eligible to do so. Therefore teams have been asked to display the stickers enclosed within their localities and bases. NSCP can also use the electronic versions of the symbol should wish to use it.

  • NSCP will support people in their own homes and care homes to avoid unnecessary admission to hospitals, to receive care in their preferred place and to be able to die in their preferred place.

    Links will be made between NSCP Care Home Support Team, Alzheimer’s Society, Community Teams, Virtual Wards, Rapid Response, Safe Haven beds, Mental Health and Mental Capacity Specialist Nurse, End of Life team, Education and Training, Avon and Wiltshire Partnership, North Somerset Council, Weston Area Health Trust and GP Leads to develop and implement further detail around the North Somerset Dementia Care Pathway with regard to end of life care for people with dementia and their carers.

    This will support achievement of Outcomes 1, 2, 3, 4, 5 and 6 of the National Dementia Declaration and Objectives 6, 9, 10, 11, 12 and 13 of the National Dementia Strategy and develop the North Somerset Dementia Strategy and Pathway.


    2014 - Second Quarter Update

    For 2014/15, NSCP has committed to maintaining compliance with Dementia Awareness training at or above 85%.  In addition to this, Dementia Next Steps training for our Community Teams and Clevedon Community Hospital to at least 50%

    Dementia Clinical Lead has been appointed in August 2014 and is responsible for taking the lead for dementia programme

    Learning Disabilities (LD) and Dementia update In LD services, we are continuing to re-inforce our pathway process. We all work in a very multi-disciplinary way with other health and social care colleague, both within our team and within wider services i.e.: district nurses, hospice, social care and GP’s. We aim to provide a comprehensive system of support that can be flexible to meet the needs of the individual and their carers – Structure with flexibility! Nursing and Psychology meet on a monthly basis to review the database of those going through the assessment process and identify who needs input re: initial or repeat cognitive and/or health/physical assessments We also involve Psychiatry as needed to these meetings to discuss particular individuals Nursing then continue to monitor and review those on the ‘post-diagnosis’ database to ensure that their changing needs are identified and monitored. A nurse and a Speech and Language Therapist from our team recently delivered on the Dementia Next Steps training session for NSCP, covering communication and behaviours that may challenge – I understand that this was well received and it is my hope that we will continue to be asked to input into such sessions in the future. lead Nurse and the Lead Psychologist are due to deliver sessions to a number of AWP teams (community and in-patient) of Learning Disabilities and Dementia in December 2015
  • NSCP will enable people with dementia and their carers, families and friends to access up to date research information about dementia and know how to participate in research if they wish.

    Using our website, links will be made available to members of the public about up to date research and opportunities related to dementia and other health related topics. The use of social media will be explored with our communications team to find the best way of reaching as many people as possible. This will support Outcome 7 of the National Dementia Declaration and Objective 16 of the National Dementia Strategy.


    2015 - Second Quarter Update

    NSCP Intranet web page has been updated to include dementia resources.

    Alzheimer’s Society groups/activities and Crossroads contacts shared with all community teams

    Hard copy of Dementia Handbook has been shared with all 26 community teams dementia link worker

    Clevedon Dementia Hub opened  18.11.14 at Clevedon Community Hospital and will be open every month for people and staff to access information, support and resources

    Ensure carers of people with dementia and delirium feel adequately supported. NSCP is reporting in October 2015: • Dementia Research Bristol attended a recent event with Dementia Link Workers to establish awareness of the dementia research register. Carers and people affected by dementia can join. Leaflets and posters will be distributed into the community teams and GP practice bases. • NSCP is a member of North Somerset Dementia Action Alliance and we have recently shared information with all the services to publish Age UK Somerset activities for people with dementia and their carers and new memory café starting in Nailsea. • Alzheimer’s Society This is Me document (a practical tool for people with dementia who are receiving professional care in any setting) is now available to NSCP teams to distribute to families living with dementia. This document provides background information about the person and includes likes, dislikes, interest, preferences and routines, enabling staff to tailor care specifically to the person’s needs.
  • NSCP will make Clevedon Community Hospital a Dementia Friendly Hospital

    An audit of the environment has taken place using the Kings Fund Enviromental tool  This has identify areas that need working on. A new working group has started to implement the changes required in the hospital. League of Friends for Clevedon Hospital have agreed the funding  for these developments both for enviromental changes and meaningful activities. We are working closely with Clevedon Dementia Action Alliance.


    2016 - Second Quarter Update

    Clevedon Hopsital has been closed since March 2016 - it is set to reopne on 2017

    A project group has been planning the colurs and scope of having an environment more dementia friendly

  • NSCP will endeavour to find meaningful ways of involving people with dementia, their carers, families and friends in improving the services we deliver.

    NSCP will use surveys to understand the experience of people accessing services, their carers, families and friends.  Survey content will be informed by partnership working with other organisations who can represent the views of people whose lives have been touched by dementia. This information will be used to inform NSCP about what has been helpful and needs enhancing and what needs re-modelling to improve peoples’ experiences.


    2016 - Second Quarter Update

    The group asked a person with dementia to sum up his experience of attending the workshops:


    “It was a good group. I really enjoyed it and wouldn’t mind another one! It played a good part.”


    Do you think it is it important to hold events like this?


    “Yes I do! Any you get, I’ll go to. ‘Because it helps me and it’ll help a lot of people, especially being on my own.”


    Key messages from these workshops illustrate the following:


    1.         Single point of access to services, support, advice and information would make a difference for people to stay connected.

    2.         People with dementia and carers are willing to share their experiences if it changes people perceptions of dementia

    3.         Support in the locality community to stay well and live as independent as possible has been helpful and timely.

    4.         Joined up services – there is confusion as to what service does what

    5.         Supportive family including grandchildren, they tell friends too then accept the situation – “to be told at the beginning helps”

    6.         Having ONE known person they knew they could call any time to sign post/ support/ assist them, would be the best benefit.

    The final draft report was sent to all GP practices through North Somerset Dementia Strategy Group

    2015 - Third Quarter Update

    Person with dementia has drawn a picture to say thank you so much for helping her.

    Focus group was held on 24 September 2014 with 5 people affected by dementia (2 people with dementia and three family members and carers)

    Carer agreed to write a case study of her experiences of looking after her mum.

    As a consequence of this work:

    These examples have been shared with NSCP Communication and Governance team

    People affected by dementia have agreed to be involved in other engagement activities.

    We have updated our intranet page to assist staff to signpost people to dementia resources.

    Involving People with dementia resource cards have been given to each dementia link worker in each community team

    Four workshops are being held in Weston Super Mare for people affected by dementia to attend between September and December 2015. These have been planned and advertised during the months of July and August 2015. Early feedback from two of the workshops held includes: What can we do to improve diagnosis? • Listen to ‘carers’ who know the person • Help improve memory – give tips i.e. memory games • Recognise the individual – everyone’s needs/wishes are different • Signposting – support – respite • Who do you go to for support? • Link nurse/co-ordinator/named contact • Good GP • Timely support • GP knowledge • Not being directed to internet to ‘self-search’ • Support at point of diagnosis How can we improve our experience of support at home or in the community? • Unsure if help / support was offered at the beginning • Anxiety about future – for example costs involved for live in care, day care, respite, bathroom conversions, pendant alarms • Transport an issue for personal outings as well as groups – although some transport is available for one GP – Dial a ride • Day centres are being used successfully. One referred by Alzheimer’s society, the other via daughter who got information from care connect. • No-one to help with the garden • If more help is needed: would contact care connect, the social worker already known to them, or Alzheimer’s society staff member who they see at a group. • Feel you need to shout loud to get things. There are two more workshops to be held and the plan will be for Dementia Lead to write up report to share with all organisations to strengthen the dementia pathway.