An example of a completed iSPACE audit toolkit from Tollerford Surgery, completed in April 2017.

1. 1
V1 Gold/Platinum status
31/1/17
Name of Surgery List Size
The Tollerford Practice 5888
Date of starting iSPACE project No of people with dementia
March 2016 35
No of care plans in place
16
Date of Completion of iSPACE No of People with dementia
April 2017 Currently coded 48
No of Care plans in place
32
 Dementia Diagnosis rates in surgeries adopting iSPACE and across all surgeries in Wessex.
 number of primary care staff trained at tier one
 % of PWD for whom a carer has been identified
 numbers of care plans for people with dementia (PWD) and their review
 % admitted as emergency admissions to hospital for PWD compared to the size of the register,
 Length of stay in hospital of patients for whom an active care plan is in place
 Numbers of primary care consultations by PWD 6 months before iSPACE and 6 months after
implementation.
IDENTIFY one or two Dementia Champions in the practice
Initiative In place Not at this time To Action
Identify one or two
Dementia Champions
GP, Dispenser, Receptionist,
HCA, Admin, ACC (Teresa Charles
– adult care co-ordinator and
carers lead) & assistant Practice
Manager
Sign up to the
Dementia Action
Alliance –
www.dementiaaction.o
rg.uk
Applied and to be a “Safe Haven”
and “Find a Loo” when in the
area.
Start a spreadsheet of
all patients who have
Dementia in your
practice from QOF
register
Started, still identifying others
through checking additional
coding.
Read the NICE guidance
on dementia
https://www.nice.org.u
k/guidance/cg42
Sent to all relevant staff.
ACC to f/up with
Dementia
Champions

2. 2
STAFF who are skilled and have time to care
Initiative In place Not at this time To Action
Arrange a clinical
meeting for GPs with
your local OPMH
Consultant to discuss
your local dementia
pathway and resources
available locally
GPs discuss patient’s
regularly with CMHT
at MARM, BIM, VW &
S/G meetings.
A meeting with just
CLINICIANS and CMHT for
additional training
purposes, may be useful.
Discuss further.
Review your Dementia
QOF template and
make it meaningful to
patients
This is ongoing work
which the GPs,
Practice Manager and
her assistant
undertake.
Arrange a training
session for whole team
which focuses on the
experience of someone
with Dementia – LMCS
“lunch and learn”
resource pack,
Dementia Action
Alliance and
Alzheimer’s Society are
among providers of
training.
Done in Oct 2016 with
Sue Sparks. Certs &
Staff Facing Guide
given. Prior to that GP
did staff training f/up
from her own
Dementia Training in
2015. Staff encouraged
to be Dementia
Friends. ACC attended
Dementia Conference
March 2016.
PM & ACC attended
BAVLAP meeting 2016
to make “Beaminster
And Villages Local
Area Planning”,
Dementia Friendly.
Further information and
training updates provided
at our monthly staff
meetings. Always keep a
slot in the agenda for
Dementia Champions to
raise new concerns or
issues and discuss how to
overcome.
Review Use of
antipsychotics and
other dementia drugs –
audit this
See GP audit. Only
one CH patient on
antipsychotic drug at
present.
Give each member of
staff the booklet
“customer facing staff
guide” from the
Alzheimer’s Society
(Costs £5 for 25
booklets) optional
Done

3. 3
PARTNERSHIP working with carers, family and friends
Initiative In Place Not at this time To Action
Identify carers for all
patients with dementia
either at the time of
referral or from letter
back from the memory
service. Use consent
letter
Done. ACC runs
Carers register &
identifies who they
care for, (may not be
for patient at our
surgery), but will still
be in need of support.
Each patient is treated
as an individual and
when the time is
right; we will always
ask & record patient’s
consent to do so, on
their medical record.
Code the carers and
ensure they are
included and invited at
all stages of the
patient’s journey
Code with carer’s
consent. Staff in
regular contact with
patients, will (with
consent), always offer
to liaise with carer or
other organisations
on their behalf if need
to, e.g. Hospital Appt.
Involve the patient
participation group in
this work and ask
patients with dementia
and their carers what
they feel will make the
surgery dementia
friendly
iSPACE to be
discussed again at
next PPG meeting.
Help with Dementia
Friendly surgery
questionnaire.
Provide regular help
at our Carers support
group. BAVLAP invited
to address meeting.
Refer the carers to your
local carer support
agencies
Routinely added to
GP’s Carer Register,
with consent.
Encouraged to
register as Carer with
local Adult Services
Dept. ACC already
holds a wide selection
of information to
support individual
carers with relevant

4. 4
issues and current
needs. Carers Packs
are built around these
accordingly.
Ensure the carers are
copied in to hospital
appointment letters so
that they are aware of
appointment dates (this
was the most common
request from patients
and carers)
Whenever possible,
consent is obtained
from patient, for staff
to phone hospitals or
include written
information regarding
family details so that
copies of appointment
dates can be sent out
to carer as well.
Give the carer and
patient a list of helpful
contacts in your area.
We have printed this
information out on
business cards – each
area will have different
information
ACC will regularly
contact carers by
phone or letter re
carer support group
dates or to arrange
routine follow up.
Offer home or
surgery, at time of
their choosing, to
discuss issues further.
It may be that a
phone call & contact
detail for new info is
all that is required.
Ensure the carer is
offered a health check,
flu jab and that we
remind them that they
can take a respite break
if needed.
This info is reminded
to carers by GPs, PNs
& ACC upon contact.
ACC will even book
apts or make initial
contact with other
agencies, if carer feels
they are struggling to
do this themselves.
Encourage carers to
look at the Alzheimer’s
Society website and
other charity websites
to make use of their
excellent resources
www.alzheimers.org.uk
www.carersuk.org
www.dementiauk.org
This information is
available on our
surgery Dementia
Leaflet , with other
information available
in the waiting room,
on our website and
available direct from
ACC.
Website needs upgrading,
but in hand.
We are also pulling
together a selection of
books for loaning to
patients through our
surgery library project,
ensuring relevance for all
ages to be included.

5. 5
ASSESSMENT and early identification of dementia
Initiative In Place Not at this time To Action
Encourage a culture
where dementia is not
stigmatised
Awareness day
arranged for 13/5/17.
Contact made with
other local community
organisations,
including shops,
Brownies and BAVLAP
for example.
To link up with others
in the community to
strengthen this
culture, e.g. Dorset
Fire & Rescue Service,
local Police CSO, Over
50’s groups, School,
Brownies, etc.
When someone is
concerned about their
memory do a formal
assessment and refer if
needed
Already do.
Any concerns from
any patient, would be
dealt with
empathetically by
surgery staff with
suggestion of GP apt
or by directing to
information resources
if preferred.
Assessments and
referrals made with
consent of patient.
Reiterate procedure to
staff.
Be aware of the need
to offer early support
after diagnosis
Recognising Memory
Loss day is aimed at
raising the importance
of this aspect.
Audit all codes such as
“cognitive decline or
mild memory
disturbance” to ensure
they have been
converted to a
Dementia code once a
formal diagnosis is
made
**** X*****
Work has already
started on audit of
these codes.
GP anticipates
completion soon,
which will then
require our final
figures to be updated.
Remind all relevant
clinical staff to code
“cognitive decline” &
“mild memory
disturbance” and
convert to relevant
dementia code once
formally diagnosed, at
next training session.
Once coded add a
“major alert” to
patient notes so that
everyone is aware of
their diagnosis
Routine procedure,
but will remind all
relevant clinical staff
to do this at next
training session. ****
Remind all relevant
clinical staff to add
major alerts at next
training session
Consider if possible to
book double
appointments for them
– they need more
time!
It is current practice
for staff to book
dementia patients a
double apt, ask how
they intend to get to it
To write up final
protocol, once the
technical issues with
icons has been
resolved.

6. 6
& if required, offer to
liaise with carer or
Country Cars. If
booked over phone,
receptionist will verify
carefully with patient
that they have written
down details correctly
& ask to read back. If
at reception desk, then
will give A4 large print
apt slip, adding in any
relevant details
regarding the apt, in
space provided, e.g.
write down how to fast
for blood test night
before or ring Country
cars.
If people with
Dementia are
consistently not
attending
appointments consider
contacting them or
their carer by phone to
remind them of the
appointment
It is Practice policy to
send reception team a
scheduled task, to
contact patient one
hour before their
appointment is due
with a reminder and
check how planning to
get there.

7. 7
CARE PLANS which are person centred
Initiative In Place Not at this time To Action
Encourage patients to
complete a personal
care plan such as the
Alzheimer’s Society
“this is me” document
in advance of their
review appointment
Care Plans have doubled
since iSPACE
implementation and
there are “this is me”
documents available at
the surgery.
Encourage patients
and their carers to
express their care
needs at an early stage
so that we make best
use of the window of
opportunity.
Anticipatory care plans
are very helpful
We also have Advanced
Care Planning booklets
available at the surgery
for patients to express
their anticipatory care
plans, when able to do
so.
Be aware of the
natural stages of
Dementia and the
symptoms of advanced
Dementia
All staff have relevant
training for their role
and this is updated
annually.
Identify those patients
who are progressing
and ensure we link up
with social care and
add patients to the
multi-disciplinary
meeting list
As a working team, these
patients are flagged up
with other relevant staff
at the Practice and
added to our VW or S/G
patient lists, to ensure
discussed at multi-
disciplinary level.
Refer on to Dementia
“post diagnosis
support services”
This is done as a matter
of course by each GP, as
situations arise.
Complete the
advanced care plan – a
DES requirement
This is also raised by the
GP and there are
booklets available in the
surgery waiting room.

8. 8
ENVIRONMENTS that are dementia friendly
Initiative In place Not at this time To Action
Good lighting, a
welcoming face at
reception and a sense
of calm
In place. Slowly
changing over to
daylight bulbs, with
limited noise
disturbance and low
visual distractions.
Remind staff of this
important factor when
at monthly training.
Read examples of
what may cause
anxiety to patients
Use of bright colours
for the staff uniforms –
pink and red have
been successful
No current uniform &
discussed. Staff aware
to put patients at ease
for happy experience.
To remind on training
days.
Consider making the
surgery a safe haven
for people who are
found wandering in the
area
Applied for this and
small lunch box,
limited change of
clothing and basic
games, puzzle, book
activities to occupy.
Uncluttered floor
space and plain carpets
In place, although MN
have a play mat in
children’s corner.
Clear signage for
toilets and exits - use
symbols
Done & on approach to
front door, painted
white edges & steps.
Arrange for a person
with dementia and
their carer to do a walk
round of the surgery -
either one of your
patients or a “mystery
shopper” who the
WAHSN will invite
Arranged before
iSPACE implemented
and will invite same
patients back for
return visit and further
opinion.
Ask the Patient
Participation Group to
get involved with the
project - to undertake
the Kings Fund – is
your health centre
dementia friendly –
audit and survey of
patients and
collaborate on creating
leaflets and any other
actions such as starting
a carers drop in every
2 to 3 months.
The PPG will be invited
to participate in the
survey of dementia
patients & carers.
They are already
involved with our
carers drop in and
some are vetted to
deliver medication
supplies to the
housebound. This is
also valuable regular
contact for patient &
feedback for surgery.

9. 9
Members are also
involved with private
prescribing, e.g. local
walking group,
Local Initiatives – Please use this space to detail any other ideas/plans you may have
The Tollerford Practice has been involved with a research project run by Integraal, through DCC.
The aim being to see how technology can help and support patients living with dementia to
remain safe and well at home. They do not necessarily have to be able to use it themselves, but
The circle of care around them at different levels of confidentiality can keep family informed of
the patient’s activity or visitors for the day.
Surgery & PPG to support BAVLAP with their initiative to make Beaminster Area and surrounding
Villages dementia friendly.
PPG to support, promote and help raise awareness at Recognising Memory Loss day 13/5/17, held
by the Tollerford Practice. Many local organisations invited from Brownies to local PCSO, plus
organisations such as Alzheimers to run Dementia Friends sessions and Dementia UK to talk about
Admiral Nurses. Also CAB or Age UK to inform re legal / financial aspects such as Power of
Attorney.
Plus Activities and Crafts to be involved with. Invite local singing group. Advertise well.
The PPG are working with us on ‘Social Prescribing’. The first part of this has been to set up
‘health walks’, which is supported by the organisation ‘walking for health’. The walks would be
led from the surgery and patients return for tea/coffee. We are sure this will be of benefit to
some of the more ambulatory dementia patients. The walks will be on prescription and referred
by the GP to make sure that the most appropriate patients are referred.
We need to support Age UK with their voluntary Good Neighbour Scheme as so many of our
patients lack companionship when sitting at home alone, to give a carer some valuable respite, if
needing assistance with shopping or are still active enough to want to go for a long walk.
Support “Forget Me Not” icon for patient alerts on S1.
Future Planning:
Dispensary labels and information to be made clearer for patients. Make dementia patients more
obvious to staff for when handing out medication, so they can discuss carefully and ensure patient
understands directions. Dispensary staff, GPs and Nurses to ensure easy to use appliances
available and techniques demonstrated with patient and follow ups made. Blister Packs already
available, to aid compliance.
Upgrade and advertise on website. Insert to be added to website when iSPACE complete.
Working with member of PPG to create much clearer, concise and simplified notice board
information.

10. 10
Completion of surgery library resources for patient’s to borrow, whether medical condition,
bereavement or dementia. All ages considered.
Photographs were taken before and will be again at completion. Await automation of our front
entrance doors and new signage at entrance from road.
The surgery waiting room chairs will slowly be reupholstered in bright wipe able material.
Some have arms, some do not.
Textured wall rail along length of corridor to reinforce way back to reception.
Future Training:
CD / video to be shown, discuss how to improve aspects of our day to day working to help
Dementia Patients & Carers. Further training on Carers too due for June 2017.
Further Dementia Friend training available at our Memory Loss day 13/5.

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