Improving end of life care for people living with dementia in Surrey Downs

ContactJane Berg, Project Lead and Head of Education, Princess Alice Hospice
Telephone01372 461823
AddressPrincess Alice Hospice, West End Lane, Esher, Surrey, KT10 8NA

This project will improve the provision of end of life care for people living with dementia in care homes within the Surrey Downs area.

This project aims to increase awareness as well as improving the implementation of the Gold Standards Framework for Care Homes (GSFCH) in care homes where patients with dementia reside. There are currently 189 care homes in Surrey that cater specifically for patients with dementia, of these only 25 have the GSFCH accreditation.

Implementation of the GSFCH will support:

  1. Reduction in repeated and inappropriate hospital admission at the end of life
  2. Provide good quality end of life care, which puts the patient and their family and carer first.
  3. Good patient outcomes in line with their needs and preferences about end of life care and choices around treatment and preferred place of death
  4. Families and carers of patients with dementia when making difficult decisions about end of life care when under pressure, because these discussions will already have taken place with the patient at an earlier time and will be recorded and referred to when necessary


  • The funding will be used by Princess Alice Hospice towards the cost of providing a training package, delivered by a fully qualified and competent EOLC Dementia Facilitator. The guidance and resource pack will include a DVD, and an online After Death Analysis (ADA) audit tool.
  • The process will begin with 4 interactive workshops, using a variety of teaching methods to implement the key GSF standards into practice, monitored and supported by the GSFCH national team. Actions will be incorporated within workshops to ensure a step by step approach. Implementing the standards into everyday practice will ensure the approach being adopted into mainstream service and therefore assuring sustainability.
  • Subsequently, after 6 to 12 months care homes can register for GSFCH accreditation on the production of a portfolio. The facilitator will be key in providing support to the individual care homes to enable them to implement the GSFCH and assemble the required evidence of the development necessary to pass the accreditation inspection which will be conducted by the national GSFCH team.
    It is expected that a total of 15 care homes will be accredited in the first instance through this project.
  • Additionally, provision and support of this training will be continued over a three year period, beyond the project phase. Care homes will also be supported through any re accreditation when necessary.


  • Increase the number of Care Homes that sign up to the Gold Standard Framework for Care Homes standards for end of life care. (Care homes will learn more about caring for people with dementia in the very best way as they approach their end of life)
  • Help patients with dementia and their families and carers to make the best choices about their wishes for their treatment and care at the end of life, when they are still well enough to have those discussions (People with dementia in care homes will be asked what they want to happen later in their illness. This will be done as early as possible so they can discuss this with families and staff)
  • Increasing the percentage of patients with dementia to die outside hospitals, if they wish to do so. (The GSFCH will have provided more skills to care home staff to help people decide, if they wish to stay in the home instead of going to hospital to die)
  • Helping GPs, care homes, carer and voluntary agencies to offer better care and improve communication between them, to benefit patients.(The care home staff, GPs, nurses, and other professional helpers will talk on a regular basis as a team to make sure best quality is care is provided to patients with dementia)
  • Support care homes to provide the best care for patients with dementia (Helping care homes use the GSFCH scheme to make sure they have the right systems and support for staff to give them the best care)
  • Help care home staff to be confident and competent to deliver high quality end of life care.(Help staff increase their skills and knowledge about looking after people with dementia at the end of life and give them the confidence to provide right care with support from specialists when needed)
  • Help care homes continually improve their practice of caring for patients with dementia. (Make sure staff understand that they need to keep up to date with the best way of providing care by having regular education and training)
  • Encourage and support patients with dementia to make end of life care decisions whilst they still are still well enough to do so and have the cognitive ability. (Make sure staff know how to discuss with a resident and their family what they wish to happen when the illness progresses)
  • Allowing patients with dementia to make an informed choice about their preferred place of death. (Make sure the person with dementia has access to information about the possible care choices and that systems are in place for everyone in the care team to work towards honoring the wishes of residents)

Anticipated outcomes

  • Increased patient choice.
  • Reduction in inappropriate admissions to hospital.
  • Improved care planning, with better attention to, and anticipation of, end of life care needs and a structured system for offering bereavement support
  • Increase in number of deaths in care homes as opposed to in the acute hospital setting.

Progress update

The project aimed to reach 15 care homes, we have exceeded that by 5, reaching a total of 20.

We are continuing to offer the GSFCH programme for 2 cohorts per year.