The King’s Fund

Patient and Family Centred Care

Improving experience of our services for patients with dementia

A summary of this work can be found in this poster:


click on image for original pdf version

In brief

The Northern Devon Healthcare NHS Trust provides acute and community services across northern and eastern Devon.

This project focuses on the pathway of care for dementia patients who access any service from North Devon District Hospital in Barnstaple and are discharged back to their usual place of residence.

This pathway involves acute clinicians, community teams including social care, GPs, the voluntary sector and carers. It is for this reason that our particular focus is on the experience during the multiple handoffs between acute, community and primary care.

We are using a variety of qualitative and quantitative methods of data collection to gain an understanding of the patient experience.

We will then map this experience against the pathway of care to discover the service hotspots and where the greatest anxiety is caused to patients.

We plan to present the findings to the organisation at a launch event, which will explore how to improve the patient and staff experience.

Our hopes and aspirations are to provide a service which:

  • Manages patients safely in their usual place of residence
  • Only admits patients when absolutely necessary
  • Identifies patients with dementia early and ensures there is information available which improves safety and experience
  • Involves patients and carers in clinical decisions
  • Is supported by staff with the right skills, training & support
  • Are integrated and co-ordinated
  • Works across teams to support timely and safe discharges

The overall aim is to see the person in the patient: that patients with dementia are cared for with dignity and compassion in a safe environment with their carers feeling fully engaged in their care.

Project aims

The subsequent aims of the project are described by the acronym FACES

Family: Staff engage with patients, families and carers to enable them to feel in control of the care and provide opportunities to be involved in the development of the dementia care experience

Assess: Personalised care plans, tailored to individual patients needs, are developed through timely assessment for, and identification of, dementia and delirium

Communication: Information about the patient is shared across the pathway to ensure personalised and co-ordinated care is given by all clinical teams

Environment: Patients with dementia are engaged in their care on a daily basis in an environment which promotes recovery

Staff: High quality, personlised patient experience is delivered through a workforce who are trained, engaged in the project and their personal well being promoted

Key activities

Family: Activities to support improvement in this workstream are:

  • Using feedback from dementia patients and carers attending memory cafes
  • Implement the real-time patient experience tracker for dementia patients in acute and community
  • Patient shadowing by the steering group and Trust Board members
  • Regularly reviewing relevant patient feedback on the care experience
  • Use patient/family/carer feedback  to inform the re-design of services or improvements in the care experience

Access: Activities to support improvement in this workstream are:

  • All adult patients are asked the Dementia/delirium screening question on admission to hospital and care plans used where appropriate
  • Patients identified with memory problems are screened using a recognised assessment tool
  • Onward referral for diagnosis to appropriate clinical teams
  • Individualised care plans are completed for all patients, regularly reviewed and explained to patients/families/carers

Communication: Activities to support improvement in this workstream are:

  • Reliable use of ‘This is Me’ across the dementia care experience (acute and community settings)
  • Families are involved in the discharge planning process including setting an estimated date of discharge (EDD)
  • Complex Care Teams are fully engaged with the discharge process
  • Develop/implement a personalised discharge pack and named contact
  • Robust handover is given to healthcare professionals & other providers on discharge
  • Dementia patients at end of life care are managed on the Liverpool Care Pathway

Environment: Activities to support improvement in this workstream are:

  • Social activities are undertaken in the hospital setting
  • Continuity/consistency of environment is maintained for patients
  • Future ward environments are designed in a dementia friendly way
  • Project team request that one ward environment is redesigned to be dementia friendly to include a day/dining room

Staff: Activities to support improvement in this workstream are:

  • Engage/involve the wider pathway team in the PFCC project
  • Hold a launch event for a cross-section of staff
  • Develop a questionnaire for understanding staff experience on the dementia pathway
  • Design and implement a Board engagement session
  • Staff in key areas complete relevant specialist training to support the management of patients with dementia

Project team

The range and diversity of team members on this project are a real strength.

The working group comprises:

Andy Burgess, Divisional General Manager, Medicine & Paediatrics

Katherine Allen, Head of Communications and Patient Experience

Adam Hickman, Consultant Psychiatrist

Jane Wason, Community Matron (Holsworthy)

Rachel Hooper,CommunityHospitalMatron (Bideford, Holsworthy andTorrington)

Linda Field, Senior Nurse Medicine

Paula Mascall, Ward Manager, NDDH

Michael Craddock, Patient Experience co-ordinator

The Steering Group comprises

Kevin Marsh, Director of Nursing and Quality

The working group meet fortnightly and action notes record progress, discussions and actions.

From January 2013, the majority of the data capture phase of the project will be complete and the project will launch to the rest of the Trust to ensure they are aware and know their role in improving the experience of patients with dementia.

Last updated: October 3, 2017