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Westcliffe Medical Practice

We are a large family practice in the centre of Shipley supporting over 11,000 patients. We were established by Dr John Craig in the 1920's and maintain our strong ethos of patient and family centred care. We aim for the highest quality care and performance by employing and supporting high caliber, well trained staff. We provide extended services in the surgery to bring care closer to the patient and we encourage all our clinicians to developing a specialist interest and also in supporting the local CCG and other regional and national organisations in developing better services for all patients. We strongly believe in training and development and support training of our future doctors, nurses, GPs and ancillary staff. We also are a practice leading and supporting Research in the Bradford Area

20 February 2017
Yorkshire and Humber
Clinical Commissioning Group, Medical, Research Sector
Local Alliances:
Yorkshire & Humber Dementia Action Alliance, Bradford District 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?

On a Local and Regional level, one of the Westcliffe Partners Dr Sara Humphrey has developed a Specialist Interest in Care of the Elderly and now supports the Bradford City & Districts Clinical Commissioning Groups, Bradford Dementia Strategy Group and the Y&H Strategic Clinical Network in developing services and pathways to support both patients with Dementia and their Carers. This has involved developing self-care and advance care planning resources to ensure patients and carers have personal choice and knowledge to live their lives well as well as ensuring that services are designed around their needs.

On a practice-based level we have actively engaged and helped develop audit tools to ensure that every patient with Dementia is support to receive a diagnosis. Our practice prevalence rate was reported as 84% at the end of April 2015 and we have high uptake of the Dementia DES (Identification and Referral enhanced services). We also employ an Advanced Nurse Practitioner to support Care Planning (Self Care, Advance Care etc.) post diagnosis

We are an active Research Practice and Dr Sara Humphrey leads the Bradford Research Clusters 1&2 and has encouraged the practice to actively engage in the 'Join Dementia Research 'Campaign.

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

Despite having a high prevalence rates in the practice, following years of active case finding we still have not reached 100% target and have a challenge in improving detection amongst hard to reach groups. We have a growing Eastern European and Pakistani population, which presented the obvious challenges around language, cultural norms and acceptance of support services. We also have a large population of > 11,000 patients-a large number of which need ‘screening ‘ under the Dementia DES which presents a challenge in terms of numbers but also in engaging and motivating staff in the screening process.

Once a diagnosis has been established, a more considerable challenge is ensuring Care Planning of all types is undertaken in a meaning & engaging way with patients and their carers, so it makes a difference to their lives. This not only involves staff awareness training but also education on the care planning process

2. Actions

  • Raising Awareness of Dementia amongst staff

    To hold a Dementia Friendly practice awareness event involving all members of the practice team to ensure they are aware of what Dementia means to an individual and to their carers and how they can support patients to access services and to live well with Dementia (what ever their role in the practice).


    Event planned for Thursday 21stJanuary

    To encourage all staff to become ‘Dementia Friends’ before the planned event



    2016 - Second Quarter Update

    Awareness Session help on Thursday 21st April 2016 for our practice and for 4 other practices in our Alliance

  • Undertaking Meaningful Care Planning for patients with Dementia and their Carers

    To undertake training sessions for doctors and all the nursing team (Advance Nurse Practitioners/District Nurses/Practice Nurses and Health Care Assistants) in awareness of the importance Dementia as a diagnosis .To ensure a good understanding of how to undertake general patient centred Care planning for patients with Dementia and then a special emphasis on undertaking Advance Care Planning, use of Self Care tools and how to support Carers. Also to ensure they are all familiar with the Care Planning tools and Resources developed on the GP computer System One and how to ensure patients and carers are aware of the local support services

    To support the Advance Nurse Practitioner to undertake the Annual Care Planning Reviews for house bound and Care Home patients and also to facilitate a Dementia Café event where ambulatory patients and Cares can come together in an informal setting to meet not only doctors and nurses for Care Planning work but also local support services while enjoying a cup of tea.

    Monitoring of the numbers of completed Dementia Annual reviews, Carers Health Checks and Advance Care Plans will allow us to monitor the success of our input.


    2016 - Second Quarter Update

    Dementia Care Planning training carried out for all clinical staff.

    Dementia 'Cafe' Type event to enable care planning and raise awareness of local support services held in March 2016 and further events planned for September 2016

  • Increasing the Dementia Diagnosis Rate by increasing the uptake of the Dementia DES in the practice and improving access for hard to reach groups

    Dementia DES

    1) To ensure continued high uptake of the Dementia DES by motivating and monitoring practice performance

    2) To work with the SCN in developing culturally sensitive tools to ensure that our hard to reach groups are included in the Dementia DES

    To start promoting and using the new Y&H SCN tool:DiADeM – Diagnosing Advanced Dementia Mandate,To helps support awareness and  diagnosis of Advanced Dementia in Care Homes .This will help support the Care Planning and End of Life Care


    Being implemented

    2016 - Second Quarter Update

    The Dementia DES has now gone but we are continuing to promote the use of the DiaDem tool in Care Homes to ensure all patients with a potential dementia are identified and offered appropriate care planning.

  • To ensure suitable policies ,resources,audits and training are in place around Safeguarding,Mental Capacity Act,DoLs,Care Planning and Antipsychotics


    1) To ensure the practice have up to date policies and procedures for Safeguarding Adults, Mental Capacity (including DoLs)

    2) To ensure the practice has a named Adult Safeguarding Lead and they have accessed suitable training and awareness around, Safeguarding Adults, MCA, Dols, and Dementia

    3) To plan a yearly Safeguarding Adults and Children’s event for staff to ensure they know how to spot the signs of abuse, access support and make an alert

    Practice Yearly event planned for March 17th 2016


    System resources developed by our practice Lead Dr Sara Humphrey with the other Clinical Leaders, CCG,SCN and CSU for Advance Care Planning, MCA, Dementia Care Planning, Self Care and now all available and accessible on System One Practice Master Template


    Yearly audits on Dementia DES,Y&H Dementia DQT Audit, QOF, Antipsychotics etc undertaken


    2016 - Second Quarter Update

    All policies in place and a shared learning event to ensure awareness of the policies undertaken in March 2016

  • Raising Awareness of Join Dementia Research and Research Generally

    The practice is part of Bradford Primary Care Research Cluster 2 and active in research. We are actively involved with developing research studies with our local care trust and one also with Leeds Becket university ‘What Works in Dementia Training and Education We would like to increase our involvement in recruiting patients to Dementia related research and also in helping patients to access research via the ‘Join Dementia Research ‘

    We are developing a patient notice board show casing how they can get involved in research and what studies we are recruiting to at present


    2016 - Second Quarter Update

    the Research Board and awareness raising for 'Join Dementia Research 'now in place

  • Ensuring the environment of the Surgery is Dementia Friendly

    Caring out the 'Is Your Health centre Demeentia Friendly' EHE Enviromental Assessment Tool

    Being implemented

    2016 - Second Quarter Update

    Audit undertaken and action planning in place to try and make changes when finances allow

  • Ensuring the Surgery is supportive and enabling when patients with Dementia and their Carers access our services

    All staff to undertake Dementia Friends awareness so they have an awareness of the condition and understand the person behind the diagnosis.

    All staff will wear dementia friendly badges and we will sign up to ''Hello my name is .....'' and ensure all staff introduce themselves and what they are going to do/how they can help by ''Hello my name is.....

    We will try and ensure that patients with Dementia and their Carers are able to choose to have flexible length appointments and at times to allow Carers to attend.

    To introduce patient centred Care Planning by introducing the 'Year of Care' What makes a difference prior to care planning appointments to allow patients and carers to set the priorities and goals that are important to them

    Being implemented

    2016 - Second Quarter Update

    All staff now wearing 'Dementia Friendly Badges' and undertaken awareness training