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Moss Street Surgery

We are a GP Practice based in Chadsmoor, Cannock, Staffordshire. We provide a full range of health care and general support to over 5000 local residents. We have 3 doctors, 3 nurses and 12 management, administrative and ancillary staff based in the Practice. For several years we have had an active Patient Participation Group and we take the views of our patients seriously. We had a CQC inspection in April 2015 and the feedback received was very positive and encouraging. Over the past 18 months we, along with many other local GP Practices, have taken the early dementia diagnosis of our patients very seriously and have participated in a local project that has increased our diagnosis rates significantly. We are now looking to identify other ways to improve our care and support for patients who have dementia and also their carers.

22 July 2016
West Midlands
Local Alliances:
Staffordshire and Stoke-on-Trent Dementia Action Alliance, Cannock Chase 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?

This Practice acknowledges and respects the philosophy of Outcome 1 which describes self-empowerment in terms of patients diagnosed with dementia having personal choice, control and influence over decisions about them.

Similarly, Outcome 2 describes the support, understanding and unprompted reviews we adhere to for our patients with dementia.

Outcome 4 mentions the access carers have to further information relevant to them, and understands which benefits they are also entitled to. The Practice has the services of a Facilitator who engages as required with carers and patients should they want or need it. They act as a valuable interface between families and the Practice.

Outcome 5 describes the benefits that early diagnosis and continued GP support can provide in helping people with dementia to continue functioning in their everyday life which makes them feel valued. This Practice is taking the steps outlined in our action plan below to help us to achieve this and to help our staff to recognise that if our patients with dementia’s behaviour becomes challenging others, staff will take time to understand why and help them to try to avoid it.

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

The main challenge faced by the Practice is the fact that the number of our patients who have been diagnosed with dementia represent slightly less than 1% of our Practice list of 5000 patients. Obviously this list also contains a large number of patients with other long term conditions who require support and significant input from the clinical and non-clinical team here. Time is therefore the greatest challenge for us in terms of being able to provide the level of support these groups require.

That said, we believe that some of the actions we have already taken, and which are described below , will ensure that people with dementia will be receiving greater support than was possible 12-18 months ago.

2. Actions

  • Increasing the diagnosis rate for people presenting with signs of dementia

    During 2014/15, the Practice participated (and continues to do so) in a local project that aspired to increase prevalence rates for dementia in the local area. On 1 April 2014, the Practice’s diagnosis rate was approximately 40%. Over the past 12 months as a result of the various components of the project, Memory Clinics held in Practice in conjunction with the local Mental Health Trust and a practice based Care Facilitator, the diagnosis rate had risen to 79% by 31 March 2015. This service is continuing in 2015/16.


    2015 - Third Quarter Update

    New member

  • Raising awareness of dementia within the practice

    The Chair of our Practice Patient Participation Group is a trained Dementia Friends Champion. Dementia Friends Champions are trained volunteers who encourage their family, friends, colleagues and local community to understand a little bit more about dementia, what it’s like to live with dementia and then turn that understanding into action.

    As a trained Dementia Friends Champion, she presented a one hour information session on 9 June 2015 to the staff at the Practice, during which they learned more about dementia and how they can help to create dementia friendly communities and in particular, a dementia friendly Practice.


    2015 - Third Quarter Update

    New member

  • Provision of up to date literature for display and dissemination within the Practice

    A member (or members) of staff and/or PPG will act as a focal point for ensuring that current literature available within the Practice for patients is up to date and that other staff are aware as to where to access it.


    2015 - Third Quarter Update

    New member