An innovative model of care across the community and care home in Corwall

ContactKate Mitchell, Joint Programme Lead Long Term Conditions, NHS Kernow CCG
Telephone01209 886643 / 07825 521384
AddressThe Sedgemoor Centre, Priory Road, St Austell, Cornwall, PL25 5AS

This project aims to improve the quality of life of people with dementia and their carers living in Corwall, ensuring they receive timely diagnosis and support to live well at home or in a care home, to end of life.

This ambitious project will mainstream and embed innovative practice in primary care and care homes. It offers a responsive, personalised approach designed to make authentic and lasting change for people with dementia and their carers in the environment they live in.

This project will ensure that people with dementia and their carers have a named link practitioner who will support them from pre‐diagnosis to end of life. They will have access to the right information at the right time by the right person. They will be signposted to appropriate services to meet the holistic needs such as housing, benefit, carer support etc. Above all, people will feel well supported, understood and involved in their care, including end of life planning.

This project has 2 separate, but linked elements that can work independently, but they would share the same governance structure including clinical leadership and are presented together to represent the potential for integration across the full pathway of community and care home lived experience.

Implementing Countywide Innovative Primary Care Diagnosis and Management Pathway
We have completed our testing and design of our desired community dementia model over the last 3 years and this project will allow rapid countywide adoption of that clearly defined function. We have worked with people with dementia and their families across these 3 years to understand their needs at every stage in the pathway. We have tested innovative models of care founded on primary care facing and community based continuous support from pre diagnosis through to end of life. We are now in the early stages of re‐designing and implementing new complex care and dementia community services to deliver improved experiences for people living with dementia (including carers). This project will create resources and capacity to support the immediate countywide adoption of this model and will accelerate the transition to the new model of care.

Creating Safe and High Quality Care Home Environments
This project will support the existing specialist in–reach care home service to implement Cornwall’s innovative toolkits: End of Life Dementia Pathway, Assess Monitor Prevent (AMP), Stop Think Assess Review (STAR) Medications in Dementia. Implementing these toolkits across Cornwall and the Isles of Scilly will ensure that people with dementia in care homes have access to high quality care. Staff will be trained to understand dementia and to respond proactively to individual’s needs in a holistic manner, sharing skills across agencies to support efficiencies. Once adopted these toolkits support staff to feel confident and capable to manage and work with individuals experiencing dementia maintaining their health, well being and safety. People living with dementia will experience high quality care where they feel content and in a state of well being with minimum complications such as un‐necessary transfers of care or undetected pain leading to increased prescribing of medications.

The toolkits mentioned above (AMP, STAR, End of Life) have been developed with staff and people living with dementia. They have been designed, tested and adopted in one locality in Cornwall (1/4 of the population) and we require the bid funds to support rapid roll out and simultaneous countywide adoption.


  • To improve the knowledge, expertise and understanding of a range of staff to ensure they have the skills and tools to provide high quality care for people with dementia from diagnosis to end of life
  • To ensure people with dementia remain independent and well at home for as long as possible, prolonging admission to care homes
  • To reduce the likelihood of people with dementia going into hospital
  • To ensure people with dementia are involved in all aspects of their care including advanced end of life planning
  • To ensure all staff working with people with dementia use the right ‘toolkits’ and working practice to achieve high quality care
  • To ensure people with dementia and their carers feel well support to ‘live well’ with dementia regardless of where they live

Anticipated outcomes

  • More people will be diagnosed with dementia and mild cognitive impairment
  • People with dementia will have at least an annual health check
  • People with dementia will have a Personalised care plan including end of life planning
  • Increased rates of carer assessments
  • People with dementia will have a named link worker
  • Increased rates of 3 monthly medication reviews
  • Reduction or cessation in prescribing of key medications including antipsychotics
  • Reduced rates of un‐scheduled admissions to hospital (especially for falls, infections, end of life)
  • Increased numbers of carer education sessions for end of life planning
  • Reduced rates of crises in the community
  • Reduced numbers of permanent long term placements
  • Increase in numbers of people with dementia with advanced care plans
  • Increase in number of people who die in a place of their choice.
  • Increased satisfaction from people with dementia and carers
  • Increased positive feedback from experiences of care by people with dementia and carers

Progress update

The 6 Primary Care Dementia Practitioners (PCDP) funded by the dementia challenge are now well established within the community setting as part of a countywide service development. An operational policy has been developed that describes the pathway and interface with secondary care mental health services to support the new model which describes roles and responsibilities at each stage of the pathway. A peer support group has been established to enable the sharing of innovative and best practice and to support the delivery of quality outcome data. All PCDPs have undertaken additional training in managing behaviours that challenge care givers from external training providers.

A meridian questionnaire has been developed to capture feedback from people with dementia and their carers. Annual health checks, diagnosis rates and access to peer support groups have increased and new peer support and activity groups have been developed.

The EOL project in care homes is now underway with creation of a new team whose requirement is to target those care homes with highest admissions to implement evidence based toolkits and training with a specific focus on embedding the EOL pathway. This has included training and information sessions with care home staff, relatives and carers of residents with dementia.