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Cambridgeshire Community Services

Cambridgeshire Community Services (CCs)- Luton Community Unit provides a range of community services for children, older people and adults across Luton. Our vision is to deliver high quality health services to the diverse communities whom we serve that gives people more choice and control over their health care and contributes to maintaining independence and improving quality of life. Our aim is to work in collaboration with organisations across the commissioning and provider community to provide seamless /integrated care that provides a person centred approach

28 November 2019
East of England
Local Alliances:
Luton 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?

CCS - Luton has worked closely with our local borough council and providers to develop the ‘Joint Commissioning Strategy – People with Dementia’ in partnership with local agencies including people living with dementia and their carers. 

We are committed to the national dementia clinical and local network and as  a local community services provider we  promise to work in partnership with people with dementia, their carers, health partners, local social and care providers,  businesses , voluntary and community sector to ensure that people with dementia with the support of their carers are enabled to live in their own homes supported with community care for as long as possible.

Key goals are to promote early recognition of dementia. Ensure our staff are aware of and can provide information to people living with dementia and their carers that will enable them to live independently within the community by accessing local support services available.

To enable people living with dementia to have the opportunity to plan for their future which ensures that their wishes for end of life care are recognized, documented and those involved in their end life care are aware of advanced care planning so that this is enabled wherever possible.

Ensure our staff are trained so that they have the appropriate skills and knowledge to support people living with dementia and their carers.

Staff use opportunities to promote health education in the prevention of Dementia .

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

Engaging with patients in the early stages of the disease to make informed choices so are able to pan for their future. Ensure staff have access to the most up to date information about local support services so that they can share this with people living with dementia and their carers Ensuring staff can be released to complete relevant training  to ensure that all staff have the appropriate skills and knowledge to support people living with dementia and their carers The need to maintain and improve joint working arrangements with NHS partners for commissioning and delivery of services at a time when partners are experiencing significant organizational restructure and economic downturn that ensures whole system collaborative dementia work continues. To make use of limited resources, including staffing and considering value for money Obtaining patient and family/carer feedback about their views on their experience of the care received

2. Actions

  • Improve the quality of care we provide to patients with dementia and their carers

    Early recognition and referral onwards for investigation

    Work with partner organisations and commissioners and the voluntary sector on local objectives agreed within the local strategy document

    Identify all patients on caseload with dementia who have informal carers and offer carers assessment.

    Improve end of life care by providing carers with information about support available and dementia information.

    Offer people living with dementia the opportunity to discuss and document their advanced care plans including end of life care planning.

    Implement the “This is me” booklet for all patients with a diagnosis of dementia.

    Develop care plans that are person centred and individualised which involves families and carers.

    Work with our Patient experience team to identify areas for improvement to patient accessible areas by using tools such as patient led assessments of the care environment and 15 steps.

    Actively participate in relevant national research and signpost patients


    2014 - Third Quarter Update

    New Member

  • Promote early recognition, detection and diagnosis

    Continue the use of a standard, national screening question for all new patients, and onward referral for investigation where indicated.

    Referral onwards to the local memory assessment clinic as appropriate

    Referral onwards to GP for further investigations as appropriate

    Staff are able to provide information to sign post patients and their carers to early support and information that promotes early diagnosis and early support.


    2014 - Third Quarter Update

    New Member

  • Development of a workforce strategy

    Appoint a dementia clinical lead from within the community nursing teams  to ensure there is clarity about dementia care pathways, onward referral, signposting and inter professional working so that patients receive care at the right time , in the right place and that carers are recognised and supported.

    Improve staff awareness and skills of the workforce in relation to dementia by ensuring all our staff will undertake dementia awareness training within 3 months of joining our trust.

    Identify and plan the ongoing training and development of the workforce and encourage staff to consider dementia modules as part of the post registration development and post graduate diploma programmes.

    Develop dementia link roles in each ream who will act as champions of care.

    Increase staff knowledge regarding local support services and information about health education regarding healthy lifestyles.


    2014 - Third Quarter Update

    New Member