What is being done?

Nurses working in Royal Cornwall Hospitals NHS Trust are actively targeting frail patients with dementia at the front door ensuring appropriate assessment, care and discharge planning is completed and that it involves the patient and carers.

The Frailty Nurses liaise with community matrons, district /specialist community nurses, care homes, care agencies, carers and family members to gain an in depth history and baseline as part of a comprehensive assessment which feeds directly into the daily MDT team meeting.

The Frailty Nurses work alongside the wards and emergency departments nursing team and junior medical staff whom we support and teach how to assess and plan care for the patient with dementia.

The Frailty Nurses:

• assist nursing teams to problem solve any behaviours that challenge, often a result of unrecognised delirium
• ensure that patients with dementia are identified and that a life story / This is me booklet is completed
• facilitate referrals to GP or memory services for patients whom have mild cognitive impairment and have not had a previous diagnosis of dementia
• promote a positive attitude towards patients with dementia and act as advocate to the patient and their family / cares
• case manage patients back into their care homes and provide written after care guidance
• actively discharge plan ensuring we transfer the appropriate information to the appropriate person this includes carers community matrons and district/specialist nurses.

What is new and different?

We are able to provide an expert service at the front door for the patient with dementia. We have been able to support and teach staff how to plan the care for a dementia patient effectively and able to transfer their care needs to community partners. We have developed care plan for dementia/mild cognitive impairment and care home advice and guidance sheet. We are positive advocates and champions for dementia care.

What difference does this seem to be making?

Improved care planning for patients with dementia. Improved knowledge of nursing staff. Life story/this is me completed on admission. Liaison with and a point of contact for community services. Starter memory boxes for all inpatient wards for RCHT to enhance patient experience. Forget me not and red tray identified on Swift Plus information board. Change of attitude and an uptake of completing correct documentation.