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Bute House Surgery

GP Surgery in Sherborne looking after approximately 5900 patients.

20 October 2017
South West
Local Alliances:
Sherborne & 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?

We look after the patient's health ensuring a holistic approach and also ensure they are able to access healthcare services in a way to suit them.  We aim to try to ensure early diagnosis to ensure the patient gets best possible care and information for support services available. We have a carer's lead who offers support and information to those that wish for it and she actively promotes her services within the practice.

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

Some people don't wish to be assessed and don't want the 'label' dementia. 

The workload of General Practice in current times, means that proactive work with patients is hard to do and we also have to consider supporting other disease groups equally.

2. Actions

  • Staff training

    Ensure all staff read and digest the Alzheimer's Society ' Customer facing staff' booklet.

    Book Dementia Lead locally to do an awareness session with all staff clinical and non-clinical.


    2017 - Second Quarter Update

    All staff received an information session from the local dementia lead which was well-received.  It generated a good discussion regarding clinical diagnosis as well as how staff could support patients and their carers better.

  • Carers of people with Dementia

    Ensure all patients with a diagnosis of dementia have had their carer identified and that carer offered support and a health check.


    2017 - Third Quarter Update

    All patients with dementia diagnosis are being reviewed to see if we hold carer details.  Work by the community HCAs are also picking these up.


  • Identifying new dementia diagnosis

    Review all patient records with 'memory loss' in their clinical record and assess to see if appropriate to call in for review.


    2017 - Second Quarter Update

    All patients with 'memory loss' in their clinical records have been identified and the community HCAs have been reviewing the patient notes and offering a review to those that have not been seen for a while in surgery.

  • Patient awareness of dementia in the community

    Run article in next practice newsletter promoting 'Dementia Friends' and dementia awareness.


    2017 - Third Quarter Update

    An article relating to dementia was placed in our practice newsletter in June 2017 and also in April 2016.

    Dementia will continue to be one of the conditions featured alongside other conditions.

  • Identifying the deteriorating patient and ensure multi-disciplinary support

    Ensure those patients that present with deteriorating symptoms are discussed at multiple disciplinary meetings and all relevant services aware of this.


    2017 - First Quarter Update

    MDT process working well now and all clinicians and locla services that participate are aware that they can put forward patients to discuss.

  • Support for patients with dementia at their home

    Use our community HCAs more to visit patients with dementia in their own homes to assess their needs and record their wishes for the future.


    2017 - Third Quarter Update

    Our community HCAs caseload of home visits has increased with more people being visited in their own homes if they need it.  Patients with dementia and those with memory problems who may need additional support form the community HCAs can be referred by any member of staff from receptionist to GP.

    The Community HCAs have developed good links with the community rehab and district nursing teams at the Yeatman hospital and will liaise with these professionals as and when the patient needs additional support.

    The practice carer's lead is also there to provide support to carers of people with dementia and can signpost to other support services.

    This will continue to be an ongoing part of the service we provide.

    2017 - First Quarter Update

    Community Health Care Assistants have reviewed their caseload with GPs and actively search to new diagnosis and visit these patients in their homes on a regular basis or as the patients wishes.

  • Clinical training for community health care assistants

    Training for community health care assistants in 'Dementia Awareness in End of Life Care' to ensure appropriate support is offered to patients.


    2017 - First Quarter Update

    Both community HCAs have completed the course run by the local hospice.  They report it was very useful for their role.

    Clinical staff participated in an interactive session from local dementia lead and was well received.