What are cookies?

Our site uses cookies. A cookie is a small text marker stored on your computer that enables us to track the use of our website. We use cookies to help us understand what our users' interests and preferences are to ensure the website is as user friendly as possible.

This site only uses cookies in order to provide a service to visitors. No personal data is stored in cookies and cookies are not used in order to provide advertising. Cookies are used for the following purposes:

Learn more about cookies on aboutcookies.org

If you have any concerns about the processing of your personal data by the Dementia Action Alliance, please contact the Secretariat, c/o Alzheimer's Society, 43-44 Crutched Friars, London, EC3N 2AE.

Accept and continue

Audley Health Centre

General Practice operating from a purpose built health centre in a semi rural village.

4 April 2017
West Midlands
Local Alliances:
Staffordshire and Stoke-on-Trent 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?

Audley Health Centre is committed to providing our patients with personal choice and involving them in all decision making ‘no decision about me, without me’.

We aim to provide appropriate information and support to both patients and carers and are working with the local CCG to design services around patient needs, with the aim that care is provided by the right person, in the right place at the right time. Specifically, we are part of a locality innovation pilot working with the combined healthcare trust, bringing specialist community nurses into the community to jointly deliver dementia annual reviews and develop bespoke personalised care plans as well as crisis management and support.

We have actively promoted the recent national initiatives around increasing dementia awareness and have used our flu clinics to deliver memory assessments to any expressing concern. We aim to provide an enabling and supportive environment where our local population feel valued and understood.

We aspire to have the Health Centre at the centre of our community and work with partners, patients and stakeholders to increase community cohesion.

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

The challenges around delivering the outcomes include a relatively low awareness of the range of voluntary services available to us locally.

We have not worked closely with voluntary sector colleagues in the past and feel that this initiative will give us the impetus to do so. Whilst we do not have the knowledge and know-how, we cannot direct patients and carers to what they need.

A second challenge will be around freeing up time to do things in a different way and work collaboratively with others.

2. Actions

  • Improve our understanding of dementia

    We will deliver dementia awareness for all practice staff via ‘dementia friends’ sessions held in the surgery and facilitated by a local dementia champion. We will encourage all staff to view the online video ‘Insights on living with and caring for those with dementia’ by Dr Jennifer Bute (a GP with dementia) http://www.gloriousopportunity.org/dvd2.php/ and give them protected time to do this.

    We will work with the local Dementia Action Alliance group and consider the role of a dementia champion within the extended practice team - this is likely to be the CPN who is working with us.

    We will organise an appropriate clinical update for all practice clinicians.


    2017 - First Quarter Update

    We have completed dementia friends training for all surgery staff and have extended this to include the patient panel (PPG).

    2016 - First Quarter Update

    Clinical Update

    We held an in-house clinical meeting for all practice clinicians. This reviewed the aetiology and pathophysiology of dementia, considered presentations and management and looked at the therapeutic treatment options available. The session was led by Rachel Massey (CPN) in conjunction with a GP

    2015 - Fourth Quarter Update

    Dementia Friends

    We have delivered dementia friends training to our practice team through a couple of sessions with 17 staff members now having undertaken the training. In addition, the Audley patient panel have also had a dementia friends session. We are proposing to deliver a final dementia friends session to cover the remaining 9 staff who could not attend.

    The sessions were well received and some good individual actions were developed.

  • Raise awareness of dementia

    We will ensure that we have appropriate up to date literature available to all staff and patients within the practice and provide displays that are kept up to date. We will also make information available via the practice website.

    We will use our TV screens and display boards to promote awareness of dementia and to invite patients to attend screening or raise concerns.

    We will actively identify patients who are ‘at risk’ of dementia and ask about memory concerns opportunistically during any contact with the clinical team.

    We will encourage a culture where dementia is not stigmatised.


    2017 - First Quarter Update

    We continue to promote early diagnosis and screening offering memory assessment to anyone who expresses concerns. During 2016-2017 we have worked with another surgery to provide assessments of all aged 85+ and offered memory screening as part of this holistic assessment

    2015 - Fourth Quarter Update

    We have actively promoted early diagnosis and screening throughout 2015-2016, offering memory assessments to anyone expressing concerns about their memory. In the 'at risk' groups, we screened twice as many people as in the preceeding year (220 vs 110)

  • Improve diagnosis rates

    We will ensure that we ask screening questions to all ‘at risk’ patients and do a formal assessment when someone is concerned about their memory. We will ensure that we follow the agreed referral pathway.

    We will ensure that all new diagnoses are captured and coded correctly and audit codes such a ‘cognitive decline’ and ‘memory disturbance’ to ensure that they have been converted to a dementia code once a formal diagnosis has been made.

    We will continue to compare our data with local and national averages and aim to achieve the ‘expected’ prevalence for our practice population.


    2017 - First Quarter Update

    We continue to actively screen for dementia and have a fairly consistent dementia register of aorund 97 patients. Of note, we have no nursing care homes in the practice catchment so when dementia becomes more severe, patients often move to a different area and a new practice

    2015 - Fourth Quarter Update

    Increasing awarenes and diagnosis rates

    We have actively screened 220 patients identified as 'at risk' of dementia in the year April 2015- March 2016: this is twice as many as in the preceding year.

  • We will work in partnership with patients, carers and the wider community

    We will identify carers. In some cases this will be by sending them a letter via the patient to ask them to identify themselves. We will code the carers and involve them in decision making and care decisions.

    We will explore mechanisms whereby carers are copied in to hospital referral letters so that they are aware of appointment dates. We will provide carers and patients with a list of ‘helpful contacts’ in the area.

    We will work with the voluntary sector to understand local resources and signpost effectively and  with CHC and community based CPN’s to ensure that the services are ‘joined up’ and using the resources most effectively.

    We will work with the wider community to become a dementia friendly village.

    Initial Scoping

    2017 - First Quarter Update

    Unfortunately a key person in the community changed role and this reduced the progress in making Audley a dementia friendly town. This has now been picked up again and work is actively occuring with both Halmerend Institute and Audley resource and information centre. We are also developing early links with Alsager who have their first dementia cafe at the end of April

    2015 - Fourth Quarter Update

    New member

  • We will develop care plans that are patient-centered

    We will encourage use of ‘This is me’ document file:///C:/Users/suttem/Downloads/Alzheimer_s_Society_This_is_me_booklet_onlinev.3.pdf

    We will encourage patients and carers to express their care needs at an early stage and consider use of anticipatory care plans

    We will work with the community CPN to develop high quality, patient centered care plans that include information around care needs and preferences.


    2015 - Fourth Quarter Update

    Care Plans

    We have actively worked with our elderly care CPN to develop high quality care plans. These have largely been developed with both patient and carer input. We have not started to use the 'This is me' document at the current time but will revisit its place.

  • We will ensure that the practice environment is appropriate

    We will keep the surgery spaces uncluttered with good lighting  and use clear signage for toilets and exits.

    We will ensure clinicians introduce themself and add context.

    We will provide a welcoming face at reception and a sense of calm wherever possible.


    2017 - First Quarter Update

    we specifically asked about clarity of signage in our most recent annual survey and had a positve repsonse. Our buidling is modern and tidy and we feel that we remain dementia friendly

    2015 - Fourth Quarter Update

    We keep the surgery spaces uncluttered with good lighting  and use clear signage for toilets and exits.

    We ensure clinicians introduce themself and add context.

    We provide a welcoming face at reception and a sense of calm wherever possible. This has been enhanced by the dementia friends training.