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Rose Court Surgery

We are a general Practice serving 11,500 patients. We have one of the highest elderly populations in Rotherham. We have 3 female gp partners and 3 male plus 1 regular locum female part time gp. We have 5 part time nurses and 4 health care assistants. We achieve well in preventing unplanned hospital admissions and endeavour to provide good preventative clinical care for our patients

28 June 2016
Yorkshire and Humber
Local Alliances:
Rotherham 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?

Though we provide good care for the physical health of our patients we would like to be more proactive in screening our patients regarding mental health issues, in particular dementia.  We have an active patient participation group and I think if we identify patients with dementia, we can provide better and earlier support. We invite someone from the carers resilience service to our monthly long term condition mdt meetings and are able to discuss the most appropriate support for the newly identified patients.   We plan to organise a carer support group to meet within Rose Court Surgery on the afternoon that it closes 



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

Over the past few months after having had the dementia awareness training, all the staff feel they want to do more, so I think there will only be a few challenges. Time is always a challenge but I think the will and effort will be there.         

  1. Use the worried about memory campaign to advertise within the surgery & on the website.
  2.   Actively search records of patients that have memory problems recorded, ensure they have been offered screening. If not engaging ensure support is offered to family and carers if possible without breaching patient confidentiality.
  3. Reassess the dementia register. Ensure all patients are reviewed and offered referral for support to services eg carer resilience assessment direct, VAR, and Alzheimer’s society.
  4. Ensure patients have been advise about eye hearing and dental checks
  5. We need to improve Front facing customer care. I plan to encourage the enthusiastic reception staff and the patient participation group to work on this aspect.



2. Actions

  • Patient records

    Flag patients records to indicate when a patient has Dementia and memory problems – smaller practices may consider new employees

  • Sensory Care

    Recommend /organise that anyone newly diagnosed to undergo a sight ,hearing and dental check to maximise the person sensory ability and comfort.

    Advise and refer patients with a dementia diagnosis  for a hearing test ,eye test and to visit a dentist to ensure their sensory needs are considered and met.

  • Monitoring system

    Have conditions which are predisposed to individuals developing dementia on the At Risk register to provide a prompt diagnosis

  • Referals and Sign Posting

    Provide after diagnosis support ,collaboratively working with 

    Alzheimers Society ,Age Uk,Crossroads ,Homeinstead  etc                                                                                                                                                  

    Any other third parties  who are working toward ensuring that People with Dementia live well as they are able

    Referral’s made to Social Prescribing 

    Referral’s Made to BME links for Social Prescribing

    Referral’s made to Carers Resilience

    Ensure AZ society literature is available ,displayed

    Being implemented
  • Registration of Carers

    Ensure Carers of PWD are registered as a carer and support is offered and issues are looked out for.

    Being implemented
  • Dementia Awareness for staff

    Ensure all staff in the practice have Dementia awareness training – this is built in to training plans as essential

    Ensure all staff are signed up as Dementia Friends                                                                                               

    Include concepts and guidance relating to Customer care from

     AZ Customer front  facing guidance booklet

    Being implemented
  • Raising Awareness

    Have Dementia messages on red screen    

    Dementia Friends

    Dementia Action Alliance

    Support Services

    Worried about your memory

    Make Dementia Awareness part of the range of features that feature on the television


  • Increased information

    Put AZ society and other support services on practice website to give support information to patients

    Create an information pack for newly diagnosed PWD and their carers – including details about the Carers information and support programme   run by AZ society

    Provision of topical notice boards including areas featuring signposting points for People and cares living with dementia

  • Dementia Friendly Physical Enviroments

    Have knowledge of good design in relation to dementia – consider designed concepts when changes are made

    Coloured toilet seats                                                                                                                                           Ensure signage is at the right level                                                                                                                Ensure signage is dementia Friendly                                                                                                                                  Avoid shinny surfaces                                                                                                                                                       Be aware that breakages in carpets and darker areas could look like steps and holes

    Consideration given to Dementia Friendly environment’s when any refurbishment/ re decorating  work is carried out

  • Support for RDAA

    Ensure all staff have knowledge of Dementia Action Alliance Rotherham and promote when ever possible

    Being implemented