This project will support people in rural areas of Bath and North East Somerset to achieve early diagnosis of dementia and get the support they want in the way that they want it, enabling people to live at home in the way that they choose.

The real innovation is that it will be a service shaped by people with dementia and their carers for people with dementia. We have based this innovative approach for people with dementia living in rural communities on the success and positive outcomes delivered by our current generic service to older people designed with our service users using the ‘in-control model’ of personalisation.

We know this approach works from our experience with our current generic service which has provided support for 40 people who have a diagnosis of dementia. We have had the opportunity to hear their feedback, to learn from that and make improvements. The personalised and accessible choices of support planning we offer have improved as a result and therefore we are confident we can meet different needs effectively and sensitively. In terms of outcomes we had a satisfaction rate of 93% with our personalised approach to support planning in our last two quarterly reports. Feedback from quarterly questionnaires and at service user meetings has included comments on how well the service is tailored to individuals.

We have a strong track record of being responsive to and co-designing our current service with our service users and representative groups. We have researched best practice and what works through the consideration of South West Dementia partnerships studies such as the ‘What works Resource Pack (2012) and the learning through ‘Living Well with Dementia’ by the Department of Health.

Basing our proposal on this learning we will design and review all aspects of our service as we go along with the people who are using it. We will be responsive to a learning approach putting the service users’ view at the centre of how we deliver services. We will engage with people in ways that suit them to ensure that they can feed into the way we deliver support, the activities we provide, the paper work we use and how we prioritise funding. We will involve service users in the evaluation of the support we provide and work with them to develop, redesign and improve services. We have experience of gathering feedback in different accessible formats. We will build on our experience using the best practice to design and develop with service users the choices of support plans that work for them.

The service will be totally personalised and will include options for fun and social activities that statutory and current services struggle to offer. There will also be help to get to these and to medical appointments. Events and activities will be developed in partnership with communities, partners and individuals as suits local need. The innovation in part also comes from the fun and creativity of our response to each individual person’s needs. We will be able to put on village events for older people where we combine information giving around Tai Chi and cookery lessons and seasonal celebrations.

Deliverables

The menu of services will be free of charge to the service user and will include the following;

• Support for people who are worried about their memory to access diagnosis/ treatment.
• Support for people with dementia and their carers to shape and influence every aspect of the service they receive
• Support for people with dementia living in rural areas who are finding it difficult to access service, get to appointments and maintain community links post diagnosis.
• Support to get good quality information for them and their carers pre and post diagnosis on dementia and access to additional services that would be useful or fun.
• Support to make changes or make plans for the future pre and post diagnosis to reflect what the individual and their families and carers want.
• Support, advice, information and referral to specialist carers service for carers who would like this.
• Face to face visits up to three times a week from an experienced Support Worker
• Support to ensure that they are getting all of their financial entitlements and to do paper work and forms where required.
• Access to information and help to navigate voluntary, statutory and health based services that will prevent or reduce the likelihood of admission or readmission to hospital, nursing care or residential care.
• 24 hour triaged response via a push button alarm service, if wanted.
• Support with telecare and access to telehealth where possible in order to enable people to self- manage better and stay living independently longer.
• Transport support to get to medical and social care appointments. Access to home repairs. Aids and adaptations to enable people with dementia to live longer and better in their home environment.
• Access to volunteer support and volunteering opportunities so that people can build links and continue to contribute to their community post diagnosis.
• Support to get to, and be involved in, social actives and events held in the local area
• Support people to be prompted to use / access medication safely when needed by engaging with pharmacies and delivery services.
• Other practical and emotional support that will enable people to make local community connections and stay living independently with their condition
• Invitations to ‘ Planning Together ‘ events every 6 weeks in different rural locations so that service users and their carers can get together, meet each other and share experiences and make connections as well as give feedback on the service they receive. These events will involve sharing a cream tea or fish and chips lunch depending on what people want.
• Invitations to Community Events to raise awareness of the needs, experiences and aspirations of people and their carers who are living with dementia.

Anticipated outcomes

We will help 45 people to:

• get the support they need in the way that they want it.
• have a real say in what we do and how we do it
• travel to Drs or hospital appointments
• make good decisions
• plan and be there if things go wrong
• access and use a push button alarm so that people can get help when they need it free of charge
• get all the money they should be getting
• meet others so they can talk to people in the same situation
• make changes to their home and get repairs to help them to stay living at home
• carry on doing the things and new things that they enjoy

Progress update

The Rural Independent Living Service is on target to meet all of our projected outcomes. We continue to design and shape teh services with people with dementia and their carers. For example we recently re-designed our publicity materials to take into account teh visual and spacial needs of people with dementia.

We continue to actively support two local memory cafes with the Alzheimers Society and the Carers Centre.

We are looking forward to our Christmas events to continue to enhance Dementia friendly communities in rural areas.

With additional scale we could reach out to more rural communitities and widen impact on a dementia friendly community.

The scope could continue to expand in response to feedback from people with dementia and their carers.