{"text_format":"1","workbook":"xlsx","n_sheets":12,"sheets":["Title","User Guide","1. Leading well","2. Preventing well","3. Diagnosing well","4a. Supporting well","4b. Supporting well","5. Living well","6. Dying Well","Supporting Information","Dashboard","Improvement Plan"],"not_rendered":{"charts":0,"images":8,"macros":0,"external_links":0,"defined_names":3,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Title","index":0,"n_rows":11,"n_cols":4,"rows_kept":11,"cut":false,"hidden":false,"merged":[[7,3,7,6],[10,2,10,6],[6,2,6,7]]}
[]
[]
[]
[]
[]
[]
[null,null,"    Dementia 100 Pathway Assessment Tool "]
[null,null,"Dementia 100 Pathway Assessment Tool for: \n(Place / ICB Area):","Complete Place or ICB area here"]
[]
[]
[null,null,"The Dementia 100: Pathway Assessment Tool is a set of 100 criteria across six pillars which collectively describe best practice standards for dementia services, from commissioning through to delivery of high-quality care at all stages of condition progression.\n\nThe tool is designed to be completed at Place, and is \"provider agnostic\" in its approach.  This Place-based assessment method means that, once the tool is completed, Places have clear direction for the development of their local plans and strategies, while Integrated Care Systems can get a bird’s eye view of areas of the pathway that are going particularly well and areas that require improvement.\n\nPlease note: This tool should be used alongside the complementary Dementia 100: Pathway Assessment Tool Implementation Guidance."]

{"sheet":"User Guide","index":1,"n_rows":20,"n_cols":11,"rows_kept":20,"cut":false,"hidden":false,"merged":[[1,1,1,16],[11,2,11,7],[12,2,14,7],[6,10,7,15],[6,5,6,7],[7,5,7,7],[5,10,5,15],[3,2,3,15],[5,2,5,7],[6,2,6,3],[7,2,7,3],[19,2,21,7],[18,10,18,15],[19,10,21,15],[11,10,11,15],[12,10,14,15],[18,2,18,7]]}
[]
[null,"Dementia 100: Pathway Assessment Tool"]
[]
[null,null,"The Dementia 100: Pathway Assessment Tool has been designed to provide a useful tool that brings together the myriad guidance that supports high quality dementia care.  \n\nBy using this tool you will be able to benchmark, review and understand where your service or system may be right now, alongside a clear path of support\nfor those areas where you need to improve.  \n\nMost importantly, this is designed to be a collaborative tool.  Just as people with dementia access multiple services and encounter health and social care professionals, volunteers, communities, so this tool brings all those parties together."]
[]
[null,null,"A. Structure of the Tool",null,null,null,null,null,null,null,"B. Completing the Tool"]
[null,null,"\nPillars:\n\nThe Dementia 100 Pathway Assessment Tool is structured under six pillars.  \n\nThe pillars are displayed as numbered tabs along the spreadsheet and each one represents a section of the tool, aligned to the Well Pathway.\n\nWhilst these pillars largely cover key stages of a dementia pathway, they are not designed to be service specific and should be reviewed and assessed as a collaborative exercise, across a Place or a System.",null,null,"\nBuilding Blocks:\n\nEach pillar is broken down into two \nor more building blocks, which focus on the contributing themes within each pillar.  \nThese appear within the pillar tabs as 'sub-headings'.\n\nCriteria: \n\nThe Dementia 100 Pathway Assessment Tool is comprised of a total of 100 criteria.  \nThese are individual statements against which a Place is able to assess themselves, using an evidence-based approach.  \n\nPriority Criteria: \n\nAcross the pillars of the Dementia 100 tool there are 14 priority criteria which have been identified nationally as key areas for focus. These are highlighted within the pillar tabs.\n\nWhere resource is constrained, these priority \nareas offer a focused set of criteria that give\na snapshot view across the full pathway.  ",null,null,null,null,"At Place level, you will need to consider the range of people and organisations that will be able to support the completion of this tool.  The 100 criteria cover all areas of dementia care and no single person can complete this - it needs to be done as a collaborative effort across the multiple agencies commissioning and providing services. You may want to allocate 'Pillar Leads' - an identified individual who can coordinate the completion of each of the pillars.  Once you have allocated the work to the right people, the tool can be completed as follows: \n\n1. Select the  Pillar Tab you have selected to work through\n2. Review the criteria statements and work collaboratively to gather the evidence of your current performance against each criteria.\n3.  Considering the evidence, agree a score to reflect your current achievement level, using the score matrix:\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n4. In the 'evidence' column, add in a brief overview of your rationale for selecting this score and details of any evidence you have used in your assessment.\n5. Decide as a Place if this criteria is an improvement priority for you - if so select 'Yes' from the drop down menu.\n6. To support further discussions, enter a name/role/organisation in the 'completed by' column\n7. If necessary, add any other comments or notes (such as details of any differences within the Place or any differences of perspectives that were discussed).\n\nTo complete the tool repeat the above steps for all criteria, so you have a comprehensive picture of the dementia provision across your Place."]
[]
[]
[]
[]
[null,null,"C. Moderating the results",null,null,null,null,null,null,null,"D. Supporting Information"]
[null,null,"Moderation at Place level:\n\nOnce you have recorded your initial scores, it is worth considering a wider discussion to moderate your results.  This will help to ensure a consistent approach to scoring has been taken across the Pillars.  Holding a collaborative meeting with a small group of stakeholders to discuss how scores have been generated can help to achieve standardisation.\n\nModeration at System level:\n\nModeration can also be done with the support of system leads, across all Places within a System. This enables Places to compare how they have each scored the same criteria and will provide a standardised view across the system, to identify and learn from high performing areas.  \n\nIdentifying a facilitator to support these moderation discussions can be beneficial.\n",null,null,null,null,null,null,null,"At any time you can view a range of additional guidance by selecting the 'Supporting Information' tab along the bottom of the tool.  Here you will find useful information on each criteria and links to relevant guidance, policies or best practice.\n\nThe supporting information for each criteria can be accessed easily by clicking on the criteria number within the pillar tabs.  Once you have reviewed the Supporting Information, you can return back to the criteria, ready to input your score by clicking again on the criteria reference."]
[]
[]
[]
[]
[]
[null,null,"E. Using the results for improvement at Place level",null,null,null,null,null,null,null,"F. Using the results for improvement at System level"]
[null,null,"Once your tool has been completed, there are two additional tabs that can support you with your ongoing plans, using the data and the findings for improvement.  \n\nDashboard\n\nThe dashboard allows you to see your achievement as a Place across all Pillars and all scores.  You will be able to see, at a glance, the percentage of the 100 criteria that have been scored at each achievement level, and how you are performing across each of the Pillar areas.  Equally you will be able to review, at a glance, your collective compliance against the 14 national priority criteria.\n\nImprovement Plan\n\nThe improvement plan tab will allow you to see a full overview of all 100 criteria achievement levels in more detail.  For all criteria that you have selected as local priorities within the pillar tabs you will be able to enter actions, owners and timescales to aid you to capture a plan for those criteria areas.  These action plan fields are also available for all the national priority criteria. \n\n",null,null,null,null,null,null,null,"There is benefit in bringing together the results from each Place to review at System level.\n\nA separate tool needs to be completed by each Place within the system.  The dashboard and improvement plan tabs can then be used to provide a direct comparison across each Place, identifying where the strengths exist across the system, where learning can be transferred from best practice, and where there are areas of collective challenge. \n\nBringing findings together for this collective system view can aid strategy development, prioritise areas for resource allocation and drive system-level improvement plans.\n"]

{"sheet":"1. Leading well","index":2,"n_rows":35,"n_cols":11,"rows_kept":35,"cut":false,"hidden":false,"merged":[[1,1,1,7],[4,1,4,7],[20,1,20,7],[25,1,25,7],[7,1,7,7],[12,1,12,7]]}
[]
[null,"Pillar 1: Leading Well\nThere is a coordinated approach to the leadership, planning, and monitoring of dementia services across a system  "]
[]
[null,"Ref:","Criteria","Score","Rationale/ Evidence","Improvement priority","Completed by\n(Name & Role)","Notes/comments ",null,"Level","Locality Level Descriptor"]
[null,"Researching Well",null,null,null,null,null,null,null,"Level 0","Not all ready to achieve/ anticipate barriers to achievement"]
[null,1.1000000000000001,"There are mechanisms in place to ensure providers are engaging in research activities, including established links with the Research Delivery Network and the recruitment of Research Champions",null,null,null,null,null,null,"Level 1","Desire to achieve this ambition but there are currently no plans in place"]
[null,1.2,"There are robust processes in place to ensure research evidence and NICE guideline updates are implemented in practice",null,null,null,null,null,null,"Level 2","Plans are in place towards achieving this ambition"]
[null,"Integrating well",null,null,null,null,null,null,null,"Level 3","Limited achievement across one or two organisations only"]
[null,1.3,"Service developments and quality improvement plans are driven by clinical data and outcomes, reviewed collaboratively across the system",null,null,null,null,null,null,"Level 4","Partially achieving - e.g. Across most, but not all care settings"]
[null,1.4,"Data sharing agreements are in place for the purposes of system-wide reporting and improvement  ",null,null,null,null,null,null,"Level 5","Fully achieving - e.g. Across all care settings, with supporting evidence available"]
[null,1.5,"There are mechanisms in place to facilitate the accurate coding of patients diagnosed with dementia in General Practice"]
[null,1.6,"Shared electronic patient records are used by multiple agencies to navigate complex pathways "]
[null,"Commissioning well"]
[null,1.7,"People living with dementia and their carers are regularly asked about what is going well and what requires improvement to inform the development of local services "]
[null,1.8,"Health and social care services undertake a process of co-production with people living with dementia when designing new services  "]
[null,1.9,"Health and social care services engage in forecasting the projected dementia population and trends for the purposes of planning services in line with the needs of the population"]
[null,1.1000000000000001,"Commissioned services are tailored to the needs of underserved groups and those from diverse communities"]
[null,1.1100000000000001,"Commissioned services take into account the individual needs of those living alone with dementia"]
[null,1.1200000000000001,"Commissioned services have improvement plans to address identified health inequality gaps  "]
[null,1.1299999999999999,"Commissioned services undertake dementia-focused equality impact assessments to evaluate the effect of service changes on the local populations and communities",null,null,"National Priority"]
[null,"Training Well"]
[null,1.1399999999999999,"Health, social care and relevant third sector organisations apply a tiered dementia training programme, which is monitored and reported",null,null,"National Priority"]
[null,1.1499999999999999,"Education and training for unpaid carers is delivered, monitored and tailored to their needs",null,null,"National Priority"]
[null,1.1599999999999999,"The community workforce who deliver palliative care and end of life care receive dedicated dementia training"]
[null,1.17,"Carers support services receive training on the specific needs of those caring for people with a young-onset dementia diagnosis"]
[null,"Monitoring Well"]
[null,1.18,"The ICB has a co-ordinated dementia strategy and improvement plan in place",null,null,"National Priority"]
[null,1.19,"The ICB has multi-agency governance in place to provide oversight and leadership  "]
[null,1.2,"Dementia performance metrics are reviewed at ICB level and overseen by a co-ordinated, multi-agency group  ",null,null,"National Priority"]
[null,1.21,"Dementia performance metrics include a focus on health inequality risk areas, such as the lack of dementia assessments in care homes"]
[null,1.22,"The ICB annually reviews the prescription rates of anti-psychotic medication for the treatment of dementia "]
[null,1.23,"Quality assurance checks are built into the commissioning of all care provision to monitor the delivery of high quality care "]
[null,1.24,"Local authorities have a current Place-based Carers' Strategy in place with a specific section on dementia "]
[null,1.25,"All providers participate in relevant national audits and results are used to drive improvements"]
[null,1.26,"There are mechanisms in place across all health and social care providers for assessing whether dignity and respect are demonstrated in the delivery of care"]

{"sheet":"2. Preventing well","index":3,"n_rows":16,"n_cols":11,"rows_kept":16,"cut":false,"hidden":false,"merged":[[1,1,1,7],[4,1,4,7],[11,1,11,7],[14,1,14,7]]}
[]
[null,"Pillar 2: Preventing Well \nThere is a coordinated approach to prevention and awareness "]
[]
[null,"Ref:","Criteria","Score","Rationale/ Evidence","Improvement priority","Completed by\n(Name & Role)","Notes/comments ",null,"Level","Locality Level Descriptor"]
[null,"Messaging well",null,null,null,null,null,null,null,"Level 0","Not all ready to achieve/ anticipate barriers to achievement"]
[null,2.1,"Healthy living messaging references dementia and provides guidance on healthy lifestyle choices",null,null,null,null,null,null,"Level 1","Desire to achieve this ambition but there are currently no plans in place"]
[null,2.2000000000000002,"Healthy ageing messaging references that addressing hearing loss and increasing social activity can reduce the risk of loneliness and dementia",null,null,null,null,null,null,"Level 2","Plans are in place towards achieving this ambition"]
[null,2.2999999999999998,"Discussions on risk factors for cardiovascular disease, and how they relate to dementia, are recorded for all NHS Health Checks.\nAdditional discussions around signs and symptoms of dementia are recorded in NHS Healthchecks for those aged 65 and above.",null,null,null,null,null,null,"Level 3","Limited achievement across one or two organisations only"]
[null,2.4,"There is consistent messaging around modifiable factors in reducing the risk of developing dementia across wider clinical services",null,null,null,null,null,null,"Level 4","Partially achieving - e.g. Across most, but not all care settings"]
[null,2.5,"Public Health initiatives around dementia have the effect of reducing stigma and offering hope, as well being realistic that dementia is a life limiting condition",null,null,null,null,null,null,"Level 5","Fully achieving - e.g. Across all care settings, with supporting evidence available"]
[null,2.6,"Dementia awareness events take place regularly within communities "]
[null,"Community assets and stakeholders"]
[null,2.7,"Dementia awareness is established in schools, colleges and universities in order to reach young people "]
[null,2.8,"Community assets are utilised for the purposes of messaging of risks and encouraging the establishment of supportive environments for people living with dementia "]
[null,"Addressing social determinants of health"]
[null,2.9,"Strategies addressing the wider and social determinants of health reference their impact on dementia risk",null,null,"National Priority"]

{"sheet":"3. Diagnosing well","index":4,"n_rows":27,"n_cols":11,"rows_kept":27,"cut":false,"hidden":false,"merged":[[17,1,17,7],[1,1,1,7],[4,1,4,7],[8,1,8,7],[12,1,12,7]]}
[]
[null,"Pillar 3: Diagnosing Well\nDiagnosis and post-diagnosis support is in place (Mental Health and Primary Care) "]
[]
[null,"Ref:","Criteria","Score","Rationale/ Evidence","Improvement priority","Completed by\n(Name & Role)","Notes/comments ",null,"Level","Locality Level Descriptor"]
[null,"Equity of access to diagnostic service providers",null,null,null,null,null,null,null,"Level 0","Not all ready to achieve/ anticipate barriers to achievement"]
[null,3.1,"There are plans in place to increase the number of people who access local dementia diagnostic services from culturally diverse and underserved communities",null,null,null,null,null,null,"Level 1","Desire to achieve this ambition but there are currently no plans in place"]
[null,3.2,"Dementia diagnostic provision is designed in a way that enables equal access for people suspected of all types of dementia, including young-onset dementia and those with learning disabilities",null,null,null,null,null,null,"Level 2","Plans are in place towards achieving this ambition"]
[null,3.3,"Referral pathways to diagnosis are reviewed annually to ensure people access and receive a diagnosis in an equitable way ",null,null,null,null,null,null,"Level 3","Limited achievement across one or two organisations only"]
[null,"Joined up approach to diagnosis ",null,null,null,null,null,null,null,"Level 4","Partially achieving - e.g. Across most, but not all care settings"]
[null,3.4,"People living with dementia are provided with a single named health or social care professional who is responsible for coordinating their care from assessment to end of life ",null,null,"National Priority",null,null,null,"Level 5","Fully achieving - e.g. Across all care settings, with supporting evidence available"]
[null,3.5,"There are formalised arrangements that enable multidisciplinary team meetings between diagnostic service provider clinicians and other specialisms"]
[null,3.6,"Dementia diagnostic service providers signpost to carer support groups available within the community "]
[null,"Timely and appropriate assessment and diagnosis"]
[null,3.7,"People with suspected dementia have an initial assessment within 6 weeks of referral and, where possible, receive a diagnosis and start treatment",null,null,"National Priority"]
[null,3.8,"Dementia diagnostic service providers have a process in place to monitor the time it takes from referral to assessment, diagnosis, and treatment which informs continuous improvement"]
[null,3.9,"Provisions are made for assessing cognitive impairment and providing treatment in urgent or crisis situations, with follow-up diagnostic pathways available"]
[null,3.1,"There is advice available for general practice to undertake accurate and appropriate referrals to diagnostic services"]
[null,"Personalised approach to diagnosis"]
[null,3.11,"Consent is sought to involve family or carers in the diagnostic process and decisions around care and treatment "]
[null,3.12,"There is a mechanism in place to enable holistic personalised care and support plans to be created and updated by all agencies involved in the care of the person with dementia ",null,null,"National Priority"]
[null,3.13,"People with a dementia diagnosis have had their care and support plan reviewed in the preceding 12 months"]
[null,3.14,"Primary care providers and commissioners monitor compliance with personalised care and support planning, in line with best practice"]
[null,3.15,"People living with dementia and their carers receive clear and documented communication on what to expect in the disease's progression and how to manage this in their personal circumstances "]
[null,3.16,"Patients newly diagnosed with dementia are encouraged to plan ahead, including considerations of the Health and Finance LPAs"]
[null,3.17,"NHS Talking Therapies is promoted as a potential avenue for treatment following a dementia diagnosis"]
[null,3.18,"There are clear onward referral pathways from local diagnostic service providers to relevant partner agencies to provide support for people living with dementia and their carers"]
[null,3.19,"Pharmacological interventions are delivered in line with the NICE dementia guideline",null,null,"National Priority"]

{"sheet":"4a. Supporting well","index":5,"n_rows":19,"n_cols":11,"rows_kept":19,"cut":false,"hidden":false,"merged":[[12,1,12,7],[16,1,16,7],[1,1,1,7],[5,1,5,7],[2,1,2,7]]}
[]
[null,"Pillar 4: Supporting Well \nThere is access to safe high quality health and social care for people living with dementia and their carers"]
[null,"Pillar 4a: Supporting Well in the community"]
[]
[null,"Ref:","Criteria","Score","Rationale/ Evidence","Improvement priority","Completed by\n(Name & Role)","Notes/comments ",null,"Level","Locality Level Descriptor"]
[null,"Post-diagnostic continuity of care",null,null,null,null,null,null,null,"Level 0","Not all ready to achieve/ anticipate barriers to achievement"]
[null,"4.1a","People living with dementia should have equal access to intermediate care (rehabilitation, reablement and recovery) provision from a person with relevant training",null,null,null,null,null,null,"Level 1","Desire to achieve this ambition but there are currently no plans in place"]
[null,"4.2a","Non-pharmacological interventions are delivered in line with the NICE dementia guideline",null,null,"National Priority",null,null,null,"Level 2","Plans are in place towards achieving this ambition"]
[null,"4.3a","People with dementia have a structured assessment before starting non-pharmacological or pharmacological treatment for distress",null,null,null,null,null,null,"Level 3","Limited achievement across one or two organisations only"]
[null,"4.4a","People with dementia have discussed and documented an advance decision about future emergency care",null,null,null,null,null,null,"Level 4","Partially achieving - e.g. Across most, but not all care settings"]
[null,"4.5a","Structured medication reviews are undertaken post diagnosis at regular intervals by Primary Care",null,null,null,null,null,null,"Level 5","Fully achieving - e.g. Across all care settings, with supporting evidence available"]
[null,"4.6a","Observational tools are used for assessing pain in people living with dementia"]
[null,"Supportive care"]
[null,"4.7a","Care providers support people living with dementia by making dementia-friendly, person-centred activities available and supporting engagement  "]
[null,"4.8a","There is a standardised approach to care provider package assessments which incorporates input from the person living with dementia, their carers and the wider MDT"]
[null,"4.9a","Care providers regularly review home-based packages of care following initial set up"]
[null,"Communication "]
[null,"4.10a","Written and verbal communications are accessible in multiple languages and for those who are visually or hearing impaired "]
[null,"4.11a","Communication aids are used to support communication with people living with dementia"]

{"sheet":"4b. Supporting well","index":6,"n_rows":30,"n_cols":11,"rows_kept":30,"cut":false,"hidden":false,"merged":[[1,1,1,7],[2,1,2,7],[26,1,26,7],[5,1,5,7],[7,1,7,7],[11,1,11,7],[19,1,19,7],[22,1,22,7]]}
[]
[null,"Pillar 4: Supporting Well \nThere is access to safe high quality health and social care for people living with dementia and their carers "]
[null,"Pillar 4b: Supporting Well in hospital"]
[]
[null,"Ref:","Criteria","Score","Rationale/ Evidence","Improvement priority","Completed by\n(Name & Role)","Notes/comments ",null,"Level","Locality Level Descriptor"]
[null,"Emergency Department ",null,null,null,null,null,null,null,"Level 0","Not all ready to achieve/ anticipate barriers to achievement"]
[null,"4.1b","Adaptations are in place to accommodate the needs of people with dementia while in the Emergency Department",null,null,null,null,null,null,"Level 1","Desire to achieve this ambition but there are currently no plans in place"]
[null,"Admission ",null,null,null,null,null,null,null,"Level 2","Plans are in place towards achieving this ambition"]
[null,"4.2b","Clinical teams have access to a dementia specialist for advice, patient review, and to facilitate good communication with people living with dementia and their carers",null,null,null,null,null,null,"Level 3","Limited achievement across one or two organisations only"]
[null,"4.3b","On admission, the person living with dementia, and their families and carers, are informed of the named clinician responsible for their care and how to access them during the hospital stay ",null,null,null,null,null,null,"Level 4","Partially achieving - e.g. Across most, but not all care settings"]
[null,"4.4b","Community care co-ordinators and professionals involved in care at home are contacted to make them aware of admission into hospital",null,null,null,null,null,null,"Level 5","Fully achieving - e.g. Across all care settings, with supporting evidence available"]
[null,"Inpatient stay "]
[null,"4.5b","Delirium screening is undertaken using a structured screening tool, such as 4AT"]
[null,"4.6b","Carers are welcomed and supported during a hospital admission, in line with John's Campaign"]
[null,"4.7b","Inpatient ward environments are designed in ways that meet the needs of people living with dementia"]
[null,"4.8b","Medication reviews are undertaken during the inpatient stay"]
[null,"4.9b","Risks associated with frailty and dementia are monitored during an inpatient stay, such as malnutrition, dehydration and falls"]
[null,"4.10b","During an acute admission to hospital, people experiencing dementia have the opportunity to review and revise their advance care plan "]
[null,"4.11b","There are person-centred, dementia inclusive activities available and an activities coordinator actively engages with inpatients living with dementia "]
[null,"Communication "]
[null,"4.12b","Written and verbal communications are accessible in multiple languages and for those who are visually or hearing impaired "]
[null,"4.13b","Communication aids are used to support communication with people living with dementia"]
[null,"Mental capacity and safeguarding"]
[null,"4.14b","All hospital staff are trained in how to raise a safeguarding concern, with specific awareness on people living with dementia "]
[null,"4.15b","A mental capacity assessment is undertaken and a Deprivation of Liberty Safeguards document and / or Mental Health Assessment is completed for all inpatients who lack mental capacity without clinical rationale"]
[null,"4.16b","There is a procedure in place for Deprivation of Liberty to be completed out of hours "]
[null,"Discharge"]
[null,"4.17b","Discharge planning is started at the point of admission, or before elective procedures, with mechanisms available to involve the multi-disciplinary team, as required"]
[null,"4.18b","Patients living with dementia, their carers and families are supported with relevant information on discharge, including as a minimum, a copy of the discharge summary, with details of medication and any future appointments"]
[null,"4.19b","There are clear and standardised pathways for appropriate referrals from hospital to dementia diagnostic service providers"]

{"sheet":"5. Living well","index":7,"n_rows":15,"n_cols":11,"rows_kept":15,"cut":false,"hidden":false,"merged":[[9,1,9,7],[1,1,1,7],[4,1,4,7],[12,1,12,7]]}
[]
[null,"Pillar 5: Living Well\nPeople with dementia can live well in safe and accepting communities"]
[]
[null,"Ref:","Criteria","Score","Rationale/ Evidence","Improvement priority","Completed by\n(Name & Role)","Notes/comments ",null,"Level","Locality Level Descriptor"]
[null,"Inclusive environments  ",null,null,null,null,null,null,null,"Level 0","Not all ready to achieve/ anticipate barriers to achievement"]
[null,5.0999999999999996,"Local authorities have policies in place to ensure their neighbourhoods are safe and welcoming for people living with dementia",null,null,null,null,null,null,"Level 1","Desire to achieve this ambition but there are currently no plans in place"]
[null,5.2,"Local authorities have plans and policies in place to improve the accessibility of the physical environment for people living with dementia ",null,null,null,null,null,null,"Level 2","Plans are in place towards achieving this ambition"]
[null,5.3,"Community events and activities that promote wellbeing are organised, and held regularly, in response to feedback from people living with dementia and their carers ",null,null,null,null,null,null,"Level 3","Limited achievement across one or two organisations only"]
[null,5.4,"Community events and activities are accessible for people living with dementia and their carers",null,null,null,null,null,null,"Level 4","Partially achieving - e.g. Across most, but not all care settings"]
[null,"Urgent neighbourhood services",null,null,null,null,null,null,null,"Level 5","Fully achieving - e.g. Across all care settings, with supporting evidence available"]
[null,5.5,"A range of suitable urgent community-based services are commissioned, including crisis prevention, urgent, and intensive support services",null,null,"National Priority"]
[null,5.6,"Ambulance services have avenues for seeking advice when required and access to suitable alternative pathways to out of hospital services "]
[null,"Supporting carers"]
[null,5.7,"Advice is given to carers about their right to carer assessment, and accessibility to respite care, breaks, and support groups",null,null,"National Priority"]
[null,5.8,"Interventions for carers are evidence-based, appropriate, and tailored according to their age, ethnicity, religion, gender, and sexual orientation"]

{"sheet":"6. Dying Well","index":8,"n_rows":15,"n_cols":11,"rows_kept":15,"cut":false,"hidden":false,"merged":[[12,1,12,7],[1,1,1,7],[4,1,4,7],[7,1,7,7]]}
[]
[null,"Pillar 6: Dying Well\nPeople living with dementia die well (End of Life & Palliative Care)"]
[]
[null,"Ref:","Criteria","Score","Rationale/ Evidence","Improvement priority","Completed by\n(Name & Role)","Notes/comments ",null,"Level","Locality Level Descriptor"]
[null,"Personalised support and care planning",null,null,null,null,null,null,null,"Level 0","Not all ready to achieve/ anticipate barriers to achievement"]
[null,6.1,"Advance care plans are offered and recorded, in line with the person's wishes",null,null,null,null,null,null,"Level 1","Desire to achieve this ambition but there are currently no plans in place"]
[null,6.2,"A systematic, proactive approach is used to identify people living with dementia who are also likely to be in the last 12 months of life",null,null,null,null,null,null,"Level 2","Plans are in place towards achieving this ambition"]
[null,"Joined up care",null,null,null,null,null,null,null,"Level 3","Limited achievement across one or two organisations only"]
[null,6.3,"People living with dementia who are also identified as likely to be in the last 12 months of life are added to the GP palliative care register",null,null,null,null,null,null,"Level 4","Partially achieving - e.g. Across most, but not all care settings"]
[null,6.4,"People living with dementia are enabled to continue living at home, and to die there if that is their wish, through effective coordination and continuity of care delivery across services",null,null,null,null,null,null,"Level 5","Fully achieving - e.g. Across all care settings, with supporting evidence available"]
[null,6.5,"Integrated multidisciplinary approaches are taken to the delivery of palliative care and end of life care for people living with dementia",null,null,"National Priority"]
[null,6.6,"People living with dementia have equity of access to timely specialist palliative care, as required"]
[null,"Knowledge and skills"]
[null,6.7,"Health and care professionals have the knowledge, skills, and confidence to undertake effective advance care planning conversations "]
[null,6.8,"Health and social care professionals have the knowledge, skills and confidence to provide high quality palliative care and end of life care to people living with dementia"]

{"sheet":"Supporting Information","index":9,"n_rows":176,"n_cols":5,"rows_kept":176,"cut":false,"hidden":false,"merged":[[2,1,2,4],[53,2,54,2],[53,3,54,3],[3,1,3,4],[8,1,8,4],[15,1,15,4],[25,1,25,4],[34,1,34,4],[4,2,5,2],[4,3,5,3],[6,2,7,2],[6,3,7,3],[6,1,7,1],[4,1,5,1],[9,1,10,1],[9,2,10,2],[9,3,10,3],[12,2,13,2],[12,1,13,1],[12,3,13,3],[16,2,17,2],[16,3,17,3],[18,2,19,2],[18,3,19,3],[92,1,92,4],[64,2,65,2],[64,3,65,3],[64,1,65,1],[72,2,73,2],[72,3,73,3],[72,1,73,1],[75,2,76,2],[75,3,76,3],[75,1,76,1],[81,1,82,1],[81,2,82,2],[167,1,167,4],[173,1,173,4],[162,1,162,4],[160,1,161,1],[160,2,161,2],[160,3,161,3],[165,1,166,1],[165,2,166,2],[165,3,166,3],[168,2,169,2],[168,3,169,3],[168,1,169,1],[114,1,115,1],[114,2,115,2],[114,3,115,3],[90,1,91,1],[90,2,91,2],[90,3,91,3],[94,1,95,1],[157,1,157,4],[163,1,163,4],[116,1,116,4],[120,1,120,4],[133,1,133,4],[121,2,122,2],[121,3,122,3],[121,1,122,1],[123,3,124,3],[123,2,124,2],[123,1,124,1],[125,1,126,1],[125,2,126,2],[125,3,126,3],[127,3,128,3],[127,2,128,2],[103,1,104,1],[28,2,29,2],[28,3,29,3],[28,1,29,1],[30,1,31,1],[30,2,31,2],[30,3,31,3],[86,3,87,3],[86,2,87,2],[86,1,87,1],[51,1,52,1],[53,1,54,1],[67,1,67,4],[71,1,71,4],[78,1,78,4],[61,1,61,4],[62,1,62,4],[18,1,19,1],[16,1,17,1],[26,2,27,2],[26,3,27,3],[26,1,27,1],[81,3,82,3],[84,2,85,2],[84,1,85,1],[84,3,85,3],[32,2,33,2],[32,3,33,3],[32,1,33,1],[43,1,44,1],[43,2,44,2],[43,3,44,3],[45,1,45,4],[46,1,46,4],[56,1,56,4],[59,1,59,4],[48,1,49,1],[48,2,49,2],[48,3,49,3],[51,2,52,2],[51,3,52,3],[113,1,113,4],[93,1,93,4],[105,1,105,4],[109,1,109,4],[112,1,112,4],[96,3,97,3],[96,2,97,2],[96,1,97,1],[98,1,99,1],[98,2,99,2],[98,3,99,3],[100,2,101,2],[100,3,101,3],[100,1,101,1],[103,3,104,3],[103,2,104,2],[94,2,95,2],[94,3,95,3],[154,1,155,1],[154,2,155,2],[154,3,155,3],[158,1,159,1],[158,2,159,2],[158,3,159,3],[127,1,128,1],[130,1,131,1],[130,2,131,2],[130,3,131,3],[138,2,139,2],[138,3,139,3],[138,1,139,1],[140,1,141,1],[140,2,141,2],[140,3,141,3],[143,2,144,2],[143,3,144,3],[143,1,144,1],[136,1,136,4],[142,1,142,4],[147,1,147,4],[148,1,148,4],[153,1,153,4]]}
[]
[null,"Ref:","Criteria","Supporting Information","Additional Resources"]
[null,"Pillar 1: Leading Well\nThere is a coordinated approach to the leadership, planning, and monitoring of dementia services across a system  "]
[null,"Researching Well"]
[null,1.1000000000000001,"There are mechanisms in place to ensure providers are engaging in research activities, including established links with the Research Delivery Network and the recruitment of Research Champions","A research lead could support collaborations with universities and seek out dementia-related research opportunities as part of a wider programme of research across the system, considering broader links to the National Institute Health and Care Research; Research Delivery Network and more specifically to patient-facing recruitment leads.  \n\nProviders should ensure people with dementia and carers can be involved in shaping research priorities, aligning with principles of participatory research.\n\nDementia leads should be actively involved in planning for increasing diagnostic capacity, particularly in the context of the potential approval of disease-modifying treatments.","Research champions: getting involved in research | NIHR"]
[null,null,null,null,"Join Dementia Research | NIHR"]
[null,1.2,"There are robust processes in place to ensure research evidence and NICE guideline updates are implemented in practice","Services, places and systems should have processes in place to ensure that NICE guideline updates and learning from research evidence are reflecting service delivery and design.  A range of resources and templates are available from NICE to support with the implementation of guidance and the identification of resource impacts.","Implementing NICE guidance | Into practice | What we do | About | NICE"]
[null,null,null,null,"Maximising the benefits of research: Guidance for integrated care systems I NHS England"]
[null,"Integrating well"]
[null,1.3,"Service developments and quality improvement plans are driven by clinical data and outcomes, reviewed collaboratively across the system","Clinical data and outcomes should be explored to identify gaps, best practice and where opportunities may exist to adopt different approaches.  Clinical outcome data might include nationally reported data, such as the NHS Outcomes Framework, along with local data appropriate to the population.\n\nA group set up to explore and understand approaches to clinical data findings could report into a Dementia Oversight / Steering Group for discussion on how the System might standardise approaches or adopt best practice.  ","NHS Outcomes Framework (NHS OF) - NHS England Digital"]
[null,null,null,null,"A Guide to ICSs | Dementia UK"]
[null,1.4,"Data sharing agreements are in place for the purposes of system-wide reporting and improvement  ","There should be a process in place to establish Data Sharing Agreements (DSAs) in order to take a collective approach to improving patient care and enabling communication and collaboration. Systems should ensure DSAs adhere to GDPR principles and include ethical guidelines for data use in dementia care.","Data Sharing Agreement Template | NHSE"]
[null,1.5,"There are mechanisms in place to facilitate the accurate coding of patients diagnosed with dementia in General Practice","The Professional Record Standards Body contains a suite of standards which define the information that is needed in a given situation when someone receives care.  Providers that are involved in diagnosis should work to these standards to ensure the information received in General Practice enables them to accurately define a person's diagnosis.\nIt is a contractual requirement for General Practice to maintain a robust dementia diagnosis register and to ensure diagnosis information is captured and shared with partner agencies.","PRSB Standards I PRSB"]
[null,null,null,null,"GP Contract 2025/26 I NHSE"]
[null,1.6,"Shared electronic patient records are used by multiple agencies to navigate complex pathways ","Staff providing care to an individual have a legal duty to keep complete, accurate and up-to-date records and, subject to the rules of Information Sharing for Direct Care, must share relevant information with others involved in providing direct care to that individual, regardless of organisational boundaries. Multi-agency dementia pathways that make available shared electronic records can support seamless patient care pathways and improve timeliness of care.","Information Sharing for Direct Care Guidance | DHSC"]
[null,"Commissioning well"]
[null,1.7,"People living with dementia and their carers are regularly asked about what is going well and what requires improvement to inform the development of local services ","Regular feedback mechanisms are established in order to gather qualitative data on a regular basis, as appropriate to the service. This feedback should be reportable through the governance structures within the system, either via the Integrated Care Board or Integrated Care Partnership in order to shape and inform service redesign.","Patient feedback and the NHS Constitution | CQC"]
[null,null,null,null,"Dementia Experience Toolkit | Alzheimer's Society"]
[null,1.8,"Health and social care services undertake a process of co-production with people living with dementia when designing new services  ","Systems should have in place proactive processes for engaging with people living with dementia and a range of mechanisms to facilitate involvement in the development and redesign of services. Efforts should be made to ensure that these involvement activities are inclusive and accommodate the needs of diverse groups. ","Working in partnership with people and communities statutory guidance I NHSE"]
[null,null,null,null,"Commissioners Involvement Guide-pdf | Alzheimer's Society"]
[null,1.9,"Health and social care services engage in forecasting the projected dementia population and trends for the purposes of planning services in line with the needs of the population","Projected population and forecasted trend data should be used to support service planning.  A range of resources and tools are available to aid medium and long term planning of NHS and care services at a system level, including demand and capacity mapping and applying fundamental principles and modelling approaches to enable healthcare system transformation.","NHS England » System level demand and capacity planning"]
[null,1.1000000000000001,"Commissioned services are tailored to the needs of underserved groups and those from diverse communities","Underserved groups may include refugees, traveller communities, and people experiencing homelessness. Consideration should be given to each individual's social circumstances, financial resources, culture, ethnicity, primary language, religion, gender and sexual orientation.\n\nAll commissioned services should have reviewed and considered cultural competency training tailored to dementia care.","Improving inclusion underserved groups I Include project I NIHR"]
[null,1.1100000000000001,"Commissioned services take into account the individual needs of those living alone with dementia","Recommended actions for ICBs to ensure that commissioned services are being designed an delivered in an equitable way for those living alone with dementia include:\n•\tAll ICBs identify or estimate how many people are living alone with dementia in their area and use this information to commission appropriate service pathways.\n•\tSystems are designed to facilitate up-to-date recording of living situation and informal support, and this is routinely recorded, so that information regarding living alone is accessible and can be shared appropriately among agencies and professionals.\n•\tNHS dementia services articulate how provision and pathways are designed or adapted to meet the needs of people living alone with dementia, and how these features are implemented as part of routine practice.\n•\tPeople living alone with dementia have access to a link worker or care co-ordinator who can assist with navigating NHS, social care and community provision, and identifying access and transport options. \n•\tServices review their provision to ensure they are inclusive and welcoming for people living alone with dementia.\n•\tAll services, including GPs and primary care teams, communicate with people living alone with dementia in line with their preferences and offer written summaries following appointments.\n• ⁠Steps are taken to strengthen the capability of community agencies and groups to include people living alone and respond to their needs.","Living alone with dementia I University of Exeter"]
[null,1.1200000000000001,"Commissioned services have improvement plans to address identified health inequality gaps  ","The National Healthcare Inequalities Improvement Programme outlines five key priorities for reducing health inequalities.  Reviewing these alongside local data and known healthcare inequalities gaps can support systems to identify areas for improvement.  Systems should be working to consider best practice to close these gaps and formulate an improvement plan, with measures, to track progress.","National Healthcare Inequalities Improvement Programme | NHSE"]
[null,1.1299999999999999,"Commissioned services undertake dementia-focused equality impact assessments to evaluate the effect of service changes on the local populations and communities","Health equality impact assessments should be completed for all new initiatives, schemes, projects, programmes and services. Each should consider as a minimum:\n- people who do not have a carer or whose carer cannot support them on their own\n- people who do not have access to affordable transport, or find transport difficult to use\n- people who have other responsibilities (such as work, children or being a carer themselves)\n- people with learning disabilities, sensory impairment (such as sight or hearing loss) or physical disabilities\n- people who may be less likely to access health and social care services, such as people from black, Asian and minority ethnic groups","Health Inequalities Impact Assessment | NHSE"]
[null,"Training Well"]
[null,1.1399999999999999,"Health, social care and relevant third sector organisations apply a tiered dementia training programme, which is monitored and reported","The Dementia Training Standards Framework details essential skills and knowledge across health and social care. The 3 Tiers are described as Awareness, Basic Skills, and Leadership. Training should cover de-escalation techniques for handling challenging situations in care settings, safeguarding individuals with dementia and caregivers, whilst enhancing understanding of the condition. Practitioners should be trained, equipped and supported to offer flexibility and implement good practice for people with individual, specific needs, such as those living alone with dementia.\nTraining records should be kept up to date and accessible for public and regulatory assurance.","Dementia awareness core skills training | HEE"]
[null,null,null,null,"Because we are human too I Alzheimer's Society"]
[null,1.1499999999999999,"Education and training for unpaid carers is delivered, monitored and tailored to their needs","Listening to the needs and preferences of those caring for people living with dementia is crucial to be able to provide what they require and not take a one-size-fits-all approach. This training can help unpaid carers to understand the reasons for distress behaviour and how to respond to or prevent it. Being equipped with the knowledge and skills to tackle some of the challenges around caring for someone with dementia can help to prevent burn-out and the experience more manageable. \n\nAppropriate training might include: \n- Understanding and managing risks in the home\n- Falls and pressure ulcer prevention \n- Safeguarding \n- Coping strategies for carers\n- De-escalation techniques","Supporting Carers I Recommendations I NG97 Guidance I NICE "]
[null,null,null,null,"Support for Carers: Online Dementia Courses | Carers Trust"]
[null,1.1599999999999999,"The community workforce who deliver palliative care and end of life care receive dedicated dementia training","A structured dementia training standards framework should be in place across health and social care (see criteria 1.14).  Systems should ensure that staff that are delivering palliative and end of life care have access to this training and that training is being utilised and training compliance is monitored.","Dementia awareness core skills training | HEE"]
[null,null,null,null,"Because we are human too I Alzheimer's Society"]
[null,1.17,"Carers support services receive training on the specific needs of those caring for people with a young-onset dementia diagnosis","The issues faced by someone with young-onset dementia may be different to those experienced by someone older and may be more likely to include considerations such as employment and managing a young family. There can be difficulties balancing the needs of the person with dementia, their children and other family members. It can be particularly hard for the parent without dementia or other family members who will need to provide more support for the family, while also trying to meet the needs of the person with dementia.  Professional carers should be aware of the specific issues that the children, spouses, and other carers of people living with young-onset dementia may be facing and be ready to provide advice and signpost to support.\n\nConsiderations should be given to:\n- How key workers, clinicians, social services and charitable organisations work closely together to provide a comprehensive service for the person with young onset dementia and their families\n- Access to age appropriate and meaningful activities which enable younger people and their families to remain engaged in their communities, retain and develop relationships and social connectedness. Age-appropriate means that the content, location and timings of activities are designed to be beneficial and accessible for younger people\n- Advice which enables the person to plan for the end of their life\n- Access to age appropriate and local respite and long term care, based in their own home or in residential care depending on the person’s wishes and needs","Young-onset dementia | Alzheimer's Society"]
[null,null,null,null,"https://youngdementianetwork.org/"]
[null,"Monitoring Well"]
[null,1.18,"The ICB has a co-ordinated dementia strategy and improvement plan in place","System level dementia vision, strategy and plans need to be deployed to provide consistency and alignment between all key stakeholders.  These should be aligned with local authority strategies and plans. It should actively work towards improvements in dementia care, reporting on progress in an accessible way for the public, staff and people living with dementia. \n\nIt is important that strategies and plans give consideration to the demographics of the population served at Place and System level using available health data. ","Expected ways of working between integrated care partnerships and adult social care providers | DHSC"]
[null,1.19,"The ICB has multi-agency governance in place to provide oversight and leadership  ","The ICB has programme governance and leadership in place to oversee activity in dementia across the system, including   robust cross organisational governance arrangements with clear designation of roles and responsibilities of partner organisations. The programme leadership team for dementia should include, as a minimum, an SRO at System Level, a Consultant Clinical Lead, a Primary Care Clinical Lead, a Senior Commissioning Manager and a Dementia Specialist.","Role of integrated care systems in improving dementia diagnosis I Kings Fund"]
[null,1.2,"Dementia performance metrics are reviewed at ICB level and overseen by a co-ordinated, multi-agency group  ","A multi-agency group should monitor the collection of performance data across the System.  This should be a priority focus and includes oversight of performance metrics, with a particular focus on: population data; the quality and appropriateness of referrals from Primary Care to Dementia diagnostic services; waiting times to assessment and diagnosis; assurance mechanisms around the accuracy of the primary care dementia register; an annual review of prescription rates for dementia treatment, including antipsychotic medications; dementia diagnosis rates in care homes.\n\nFurther consideration may be given to: delayed hospital discharges and progression of onward pathway for patients with delirium and dementia; outcomes of patients diagnosed with delirium and dementia; dementia annual reviews carried out by primary care. ","Role of integrated care systems in improving dementia diagnosis I Kings Fund"]
[null,1.21,"Dementia performance metrics include a focus on health inequality risk areas, such as the lack of dementia assessments in care homes"," ICSs can consider publishing annual equity reports, highlighting diagnostic and treatment disparities across demographic groups and introducing dementia-specific health equity audits to ensure ongoing improvement in access.","Increasing the Diagnosis Rate in Care Homes (pub May 2023)"]
[null,1.22,"The ICB annually reviews the prescription rates of anti-psychotic medication for the treatment of dementia ","According to a number of research studies, antipsychotics are frequently prescribed for dementia patients with limited monitoring of their side effects, and they are often prescribed for lengthy periods (more than 6 months). The benefits of antipsychotic treatment for dementia patients over longer periods are still unknown. Monitoring how these drugs are prescribed could involve an annual audit to ensure that antipsychotic medication prescribing is appropriate among this cohort of patients and that providers are following national guidance. Monitoring should include reviewing use of psychosocial interventions before prescribing antipsychotics.","Antipsychotic Prescribing Toolkit for Dementia | NHSE"]
[null,1.23,"Quality assurance checks are built into the commissioning of all care provision to monitor the delivery of high quality care ","Commissioning processes should monitor the delivery of services in line with policies, procedures and national standards, taking into account feedback gathered from people affected by dementia. All care provision refers to care provided in care homes and private residences.","Commissioners Involvement Guide-pdf | Alzheimer's Society"]
[null,1.24,"Local authorities have a current Place-based Carers' Strategy in place with a specific section on dementia ","Where the responsibility for carers' services are shared across Place or System, health and social care strategies to support carers should be aligned and should specifically recognise the unique requirements for young carers and carers of those who live with dementia.","Supporting carers guidance and case studies I LGA"]
[null,1.25,"All providers participate in relevant national audits and results are used to drive improvements","Engagement in national clinical audits should include, but not be limited to, the National Audit of Dementia (NAD) is a national clinical audit programme, the results of which are used to progress and support improvements in dementia care.","National Audit of Dementia | Royal College of Psychiatrists"]
[null,1.26,"There are mechanisms in place across all health and social care providers for assessing whether dignity and respect are demonstrated in the delivery of care","It is of critical importance that CQC Regulation 10: Dignity and respect is adhered to and evidence of adherence is gathered. \nProvider organisations need to have mechanisms in place to robustly assess that dignity and respect are being given to patients. This includes staff treating them in a caring and compassionate way. All communication with people using services must be respectful and staff must respect people's personal preferences, lifestyle and care choices.  Practices that could be used include observational assessments and spot-check audits. Patient and carer feedback should also be used as a strong indicator against this criteria. ","Regulation 10: Dignity and respect | CQC"]
[null,null,null,null,"Intercultural Dementia Care: A Guide for Health and Care Workers | NHSE"]
[null,"Pillar 2: Preventing Well \nThere is a coordinated approach to prevention and awareness "]
[null,{"$f":"'2. Preventing well'!B5","v":"Messaging well"}]
[null,{"$f":"'2. Preventing well'!B6","v":2.1},"Healthy living messaging references dementia and provides guidance on healthy lifestyle choices","Healthy lifestyle choices that can reduce the risk of developing Alzheimer's Disease and vascular dementia include: reducing caffeine and alcohol intake, avoiding use of tobacco and recreational drugs and ensuring physical activity, good levels of sleep and nutrition.","Dementia: Reducing Your Risk | Alzheimer's Society"]
[null,{"$f":"'2. Preventing well'!B7","v":2.2000000000000002},"Healthy ageing messaging references that addressing hearing loss and increasing social activity can reduce the risk of loneliness and dementia","Addressing loneliness or social isolation requires personalised interventions tailored to the unique needs of individuals, specific groups, or the feelings of loneliness they experience, as there is no universally applicable solution. Adherence to NICE Guidelines NG16 Dementia, disability and frailty in later life – mid-life approaches to delay or prevent onset and NG32 Older people: independence and mental wellbeing is required.\n\nTo support the messaging system needs to look at the services they have available to address hearing loss and social inactivity such as community programmes, digital health tools, and social prescribing initiatives.\n\nPersonalised interventions can be delivered through local dementia-friendly initiatives that address barriers to social participation (e.g., transport, affordability, digital literacy).","Recommendations | NG16 | Dementia, disability and frailty in later life | Guidance | NICE"]
[null,null,null,null,"Recommendations | NG32 | Older people: independence and mental wellbeing | Guidance | NICE"]
[null,{"$f":"'2. Preventing well'!B8","v":2.2999999999999998},"Discussions on risk factors for cardiovascular disease, and how they relate to dementia, are recorded for all NHS Health Checks.\nAdditional discussions around signs and symptoms of dementia are recorded in NHS Healthchecks for those aged 65 and above.","The NHS Health Check programme is designed to identify those at risk of cardiovascular disease and those who may require further medical supervision.  Modifiable factors to reduce the risk of cardiovascular disease and dementia should be discussed including, for example, smoking, weight management, and alcohol use.  \nNHS Health Checks for those aged over 65 should include further information designed to raise their awareness of dementia and the routes to assessment and diagnosis.","NHS Health Check (information for patients)"]
[null,{"$f":"'2. Preventing well'!B9","v":2.4},"There is consistent messaging around modifiable factors in reducing the risk of developing dementia across wider clinical services","There is an increasing evidence base that demonstrates the steps people can take to reduce their risk of developing certain dementias or to delay their onset and the recognition of the importance of raising awareness to help with this. Young-onset Dementia is one of the lesser known dementias and requires some focus in awareness raising as there are a number of modifiable factors to consider.","Reduce your risk of dementia | Alzheimer's Society"]
[null,null,null,null,"Young-onset dementia | Alzheimer's Society "]
[null,{"$f":"'2. Preventing well'!B10","v":2.5},"Public Health initiatives around dementia have the effect of reducing stigma and offering hope, as well being realistic that dementia is a life limiting condition","\"Life-limiting condition\" is a term used to describe an incurable disease that will shorten a person's life, though they may continue to live active lives for many years. It could also refer to the challenges that people with dementia face that may affect their day-to-day quality of life. Public health initiatives aimed at dementia stigma reduction should be co-produced with people living with dementia and their families.","The progression of Alzheimer's Disease and other dementias | Alzheimer's Society "]
[null,null,null,null,"Dealing with Stigma | Dementia UK"]
[null,{"$f":"'2. Preventing well'!B11","v":2.6},"Dementia awareness events take place regularly within communities ","Events within communities might include workshops, seminars, information sharing sessions, peer support groups, memory cafes, fundraising events, art exhibits, film screenings, and educational talks. These events serve to educate the public, provide support to caregivers, and foster understanding and empathy towards individuals living with dementia.\n\nEvents should be targeted at underserved communities, ensuring accessibility for diverse populations.\n\nDigital and hybrid event formats should be encouraged to reach rural and underserved communities.","Activity groups for people with dementia and their carers | Alzheimer's Society"]
[null,{"$f":"'2. Preventing well'!B12","v":"Community assets and stakeholders"}]
[null,{"$f":"'2. Preventing well'!B13","v":2.7},"Dementia awareness is established in schools, colleges and universities in order to reach young people ","This process could involve implementing educational programs, workshops, guest lectures, and interactive sessions tailored to young people (e.g. dementiafriends.org.uk). These initiatives aim to educate students about dementia, its impact on individuals and society, risk factors, prevention strategies, and how they can support those affected by the condition. Additionally, it may involve promoting volunteer opportunities or projects related to dementia care and research, encouraging students to engage actively in raising awareness and supporting initiatives in their communities. This process could be taken away from an institutional setting and focus on family members such as grandchildren / children sharing knowledge of the expectation of living with a person with dementia.","Let's Create a Dementia-Friendly Generation | Alzheimer's Society"]
[null,{"$f":"'2. Preventing well'!B14","v":2.8},"Community assets are utilised for the purposes of messaging of risks and encouraging the establishment of supportive environments for people living with dementia ","Local health and care systems should scope out and, where possible, collaborate with existing community assets, such as libraries, faith groups, and voluntary sector organisations, to support dementia prevention messaging.\n\nBusinesses should be encouraged to participate in Dementia Friendly initiatives such as promoting dementia-inclusive environments.","Communities | Dementia | Resources | Housing LIN"]
[null,{"$f":"'2. Preventing well'!B15","v":"Addressing social determinants of health"}]
[null,{"$f":"'2. Preventing well'!B16","v":2.9},"Strategies addressing the wider and social determinants of health reference their impact on dementia risk","Wider determinants of health are a diverse range of social, economic and environmental factors which impact on people's health. They're also known as social determinants. These factors are influenced by the local, national and international distribution of power and resources which shape the conditions of daily life. This criterion requires health and social care systems to include structural factors that affect the risk of developing dementia are being addressed in relevant strategies, such as air quality, noise levels, social isolation, active travel policies, deprivation, and access to lifelong education. ","Wider Determinants of Health | Fingertips Data | PHE"]
[null,"Pillar 3: Diagnosing Well\nDiagnosis and post-diagnosis support is in place (Mental Health and Primary Care) "]
[null,{"$f":"'3. Diagnosing well'!B5","v":"Equity of access to diagnostic service providers"}]
[null,{"$f":"'3. Diagnosing well'!B6","v":3.1},"There are plans in place to increase the number of people who access local dementia diagnostic services from culturally diverse and underserved communities","Services and commissioners should seek to understand the potential cultural barriers that exist within their communities to accessing dementia diagnostic services.  These may include language barriers, cultural accessibility or stigma barriers, or cultural perceptions, including about caregiving staff.  Consideration could be given to commissioning community-based engagement programmes to improve awareness and access. Cultural competency training should be embedded into professional development for all diagnostic staff.","Increasing Access to Diagnosis for Ethnic Minority Groups | Alzheimer's Society"]
[null,{"$f":"'3. Diagnosing well'!B7","v":3.2},"Dementia diagnostic provision is designed in a way that enables equal access for people suspected of all types of dementia, including young-onset dementia and those with learning disabilities","Getting an accurate and timely diagnosis of dementia is important, no matter the type of dementia being assessed. As atypical, rarer types of dementia can present differently from Alzheimer’s Disease and symptoms may be harder to recognise (changes may not be in memory but in behaviour, language, vision, or personality), it is crucial that service providers have in place robust assessments and processes to ensure that there is equity of access to a diagnosis. ","DIAMOND-Lewy I Assessment Toolkits I Newcastle University"]
[null,null,null,null,"Resources for clinicians I Resources I Young Dementia Network"]
[null,{"$f":"'3. Diagnosing well'!B8","v":3.3},"Referral pathways to diagnosis are reviewed annually to ensure people access and receive a diagnosis in an equitable way ","A review of referral pathways may examine whether the service provider offers home assessments and what arrangements are in place for assessing people suspected of having dementia in care homes. It may form part of a health equity audit to ensure equity of access to the service. \n\nRegular audits and referral pathway evaluations that take into account patient and carer experience feedback are useful tools to assess equity in diagnostic referrals. Audits and evaluations should examine all care settings and Health Equity Audits can further evaluate barriers to access for minority and socially deprived groups.  ","Health equity assessment tool I Publications I Government"]
[null,{"$f":"'3. Diagnosing well'!B9","v":"Joined up approach to diagnosis "}]
[null,{"$f":"'3. Diagnosing well'!B10","v":3.4},"People living with dementia are provided with a single named health or social care professional who is responsible for coordinating their care from assessment to end of life ","This named person is a point of contact between all services (primary, secondary and tertiary). Named professionals should receive specialist dementia care coordination training.\nNICE guideline recommendations in NG97, Dementia: assessment, management and support for people living with dementia and their carers states that the named professional should: \n- arrange an initial assessment of the person's needs, which should be face to face if possible\n- provide information about available services and how to access them\n- involve the person's family members or carers (as appropriate) in support and decision-making\n- give special consideration to the views of people who do not have capacity to make decisions about their care, in line with the principles of the Mental Capacity Act 2005\n- ensure that people are aware of their rights to and the availability of local advocacy services, and if appropriate to the immediate situation an independent mental capacity advocate\n- develop a care and support plan with the involvement of the person, their family members or carers (as appropriate) and relevant professionals ","Quality Statement 4 | QS 184 | Coordinating care | Guidance | NICE "]
[null,{"$f":"'3. Diagnosing well'!B11","v":3.5},"There are formalised arrangements that enable multidisciplinary team meetings between diagnostic service provider clinicians and other specialisms","Other specialisms may include neurology, psychiatry, neuropsychology and neuroradiology as part of the multidisciplinary team.\n\nThere should be a standardised approach to MDT meeting schedules across ICSs and audit measure utilised to track the impact of MDT discussions on diagnostic outcomes.","Clinical features and multidisciplinary approaches to dementia care I NIHR"]
[null,{"$f":"'3. Diagnosing well'!B12","v":3.6},"Dementia diagnostic service providers signpost to carer support groups available within the community ","Professionals working with people living with dementia need to ensure robust mechanisms to identify unpaid carers to enable signposting to relevant, culturally appropriate support groups.  Dementia Cafes are one example of dementia-specific social spaces for carers to access peer support. \n\nProviders should consider how the may bee able to standardise post-diagnostic support pathways for carers and the introduction of routine carer \"well-being\" checks post-diagnosis, providing opportunities to support and encourage engagement.","Peer Support: Sharing experiences in a safe and supportive environment | Alzheimer's Society"]
[null,{"$f":"'3. Diagnosing well'!B13","v":"Timely and appropriate assessment and diagnosis"}]
[null,{"$f":"'3. Diagnosing well'!B14","v":3.7},"People with suspected dementia have an initial assessment within 6 weeks of referral and, where possible, receive a diagnosis and start treatment","Providers and commissioners should accessibility of dementia assessment within 6 weeks of referral, through seamless referral pathways, oversight of performance and improvement plans where barriers to achieve this exist.  Wherever possible, this timeliness should also include diagnosis and treatment, to ensure people living with dementia have access to post-diagnostic support at the earliest opportunity and the best possible treatment options. ","Improving access to a timely and accurate diagnosis I Alzheimer's Society"]
[null,null,null,null,"Diagnosis I Quality Statement 2 I QS184 I NICE"]
[null,{"$f":"'3. Diagnosing well'!B15","v":3.8},"Dementia diagnostic service providers have a process in place to monitor the time it takes from referral to assessment, diagnosis, and treatment which informs continuous improvement","Regular monitoring of time to assessment and diagnosis should be undertaken and reported centrally through the governance structures of the Integrated Care Board and/or Integrated Care Partnership. \n\nPatient experience surveys can support systems to understand the impact of waiting times."]
[null,{"$f":"'3. Diagnosing well'!B16","v":3.9},"Provisions are made for assessing cognitive impairment and providing treatment in urgent or crisis situations, with follow-up diagnostic pathways available","In urgent or crisis situations, there should be clear protocols and pathways in place for urgent community teams to be able to draw on expertise from across Place to ensure timely assessment, triage and onward referrals.","High Impact Change I LGA"]
[null,null,null,null,"A scoping review of crisis teams managing dementia in older people I NIHR"]
[null,{"$f":"'3. Diagnosing well'!B17","v":3.1},"There is advice available for general practice to undertake accurate and appropriate referrals to diagnostic services","When a person, their family or carer suspects a diagnosis of dementia, they often first go to see their GP. They may have concerns about impaired memory, mood and personality changes or psychosis that could be caused by dementia. The GP will conduct an initial assessment to rule out any underlying physical or mental health causes. If further investigation is required, an onward referral will be made to a memory assessment service. It is important that GPs are supported by diagnostic service providers to ensure that appropriate referrals are made to avoid distressing patients and wasting resources. Referral to a specialist diagnostic service should only take place if reversible causes of cognitive decline (including delirium, depression, sensory impairment [such as sight or hearing loss] or cognitive impairment from medicines associated with increased anticholinergic burden) have been investigated and dementia is still suspected.","Diagnosis I Dementia I CKS I NICE"]
[null,{"$f":"'3. Diagnosing well'!B18","v":"Personalised approach to diagnosis"}]
[null,{"$f":"'3. Diagnosing well'!B19","v":3.11},"Consent is sought to involve family or carers in the diagnostic process and decisions around care and treatment ","Robust processes should be in place that ensure consent is sought and recorded with regards to the involvement of family members and carers, where appropriate.","No decision about me without me | DHSC"]
[null,{"$f":"'3. Diagnosing well'!B20","v":3.12},"There is a mechanism in place to enable holistic personalised care and support plans to be created and updated by all agencies involved in the care of the person with dementia ","Commissioners should ensure that all professionals working with people living with dementia have the necessary competencies and ability to complete a personalised care and support plan (PCSP). The NHSE Good Personalised Care and Support Planning guidance provides information to primary care providers and commissioners of the key considerations and components.  Commissioners should seek assurance routes to ensuring staff are able to complete PCSPs and share them across all agencies involved.","Good Personalised Care Support Planning: Information for Primary Care Providers and Commissioner | NHSE"]
[null,{"$f":"'3. Diagnosing well'!B21","v":3.13},"People with a dementia diagnosis have had their care and support plan reviewed in the preceding 12 months","In line with General Practice contractual requirements, and as part of the Quality Outcomes Framework, GPs are required to ensure a review of a person's care and support plans within the preceding 12 months.  This is outlined within the 'Professional Record Standards Body' standard for Personalised Care and Support Plans.\nReviews should consider the requirements outlined within NICE Quality Standard QS184 and should include proactive linking with local community services to support the person's social and physical wellbeing and make best use of all the resources available.","PRSB Standards I PRSB"]
[null,null,null,null,"Dementia: care planning | Indicators | NICE"]
[null,{"$f":"'3. Diagnosing well'!B22","v":3.14},"Primary care providers and commissioners monitor compliance with personalised care and support planning, in line with best practice","It is imperative that care home residents have a personalised care and support plan in place which records personal preferences for current and future care needs. This is a contractual requirement set out in the Enhanced Health in Care Homes Framework and audits should be carried out by the care provider to ensure compliance.","Good Personalised Care Support Planning: Information for Primary Care Providers and Commissioner | NHSE"]
[null,{"$f":"'3. Diagnosing well'!B23","v":3.15},"People living with dementia and their carers receive clear and documented communication on what to expect in the disease's progression and how to manage this in their personal circumstances ","People diagnosed with dementia and their families and carers may wish to access information about the disease trajectory and the impact that this may have on their lives. \nAll information should be available in multiple languages and in suitable formats for those who are visually/hearing impaired or with Learning Difficulties and Autism. Children and grandchildren should be included in discussions where appropriate.","Living with Dementia Toolkit: Living Your Life with Hope | University of Exeter"]
[null,null,null,null,"The Dementia Guide I Publications I Alzheimer's Society "]
[null,{"$f":"'3. Diagnosing well'!B24","v":3.16},"Patients newly diagnosed with dementia are encouraged to plan ahead, including considerations of the Health and Finance LPAs","Planning ahead involves considerations such as discussing advance decisions around future treatment wishes, setting in place a lasting power of attorney, making a will, and the person's preferred place of care and death. \nThis advice typically involves educating individuals on the importance of appointing trusted individuals to make decisions on their behalf regarding their health and welfare needs, as well as their financial matters, should they become unable to make these decisions themselves in the future. Additionally, it may include information on the legal process involved in creating Last Power of Attorney (LPA), the rights and responsibilities of appointed attorneys, and the potential implications of not having LPAs in place.","My Future Wishes: Advance Care Planning for People with Dementia | NHSE"]
[null,null,null,null,"Guidance: Lasting Power of Attorney | Dementia UK "]
[null,{"$f":"'3. Diagnosing well'!B25","v":3.17},"NHS Talking Therapies is promoted as a potential avenue for treatment following a dementia diagnosis","Talking Therapies is recommended as one way that a person newly diagnosed with dementia and their families/carers can access a psychotherapy service as one of a range of support services available.","NHS Talking Therapies | NHSE"]
[null,{"$f":"'3. Diagnosing well'!B26","v":3.18},"There are clear onward referral pathways from local diagnostic service providers to relevant partner agencies to provide support for people living with dementia and their carers","Diagnostic service providers should be able to signpost to appropriate referral pathways and other services post-diagnosis. Efforts should be made to work collaboratively where this would be of benefit to people affected by dementia with the person being empowered to make decisions about their care by being informed by care options and pathways.\n\nFollow-on support might come from disciplines such as psychiatry, psychology, geriatrics, mental health occupational therapy, social work and dementia advice / navigation services, and speech and language therapy. Local services might include peer support groups and advice lines run by third sector organisations in the area. Support might include cognitive behavioural therapy, breakaway training, housing and financial advice."]
[null,{"$f":"'3. Diagnosing well'!B27","v":3.19},"Pharmacological interventions are delivered in line with the NICE dementia guideline","Medicines for managing dementia are prescribed, where appropriate, in line with NICE guideline NG97.","Pharmacological interventions for dementia I Recommendations I NG97 I Guidance I NICE"]
[null,null,null,null,"Maintenance Cognitive Stimulation Therapy | Age UK "]
[null,"Pillar 4a: Supporting Well in the Community\nThere is access to safe high quality health and social care for people living with dementia and their carers "]
[null,{"$f":"'4a. Supporting well'!B6","v":"Post-diagnostic continuity of care"}]
[null,{"$f":"'4a. Supporting well'!B7","v":"4.1a"},"People living with dementia should have equal access to intermediate care (rehabilitation, reablement and recovery) provision from a person with relevant training","Assessment and interventions should be provided to people in their home (or care home) aiming to help them recover skills and confidence and maximise their independence. Standard interventions often last up to 6 weeks, however people living with dementia may need longer, phased, or repeated support due to the progressive nature of their condition. Reablement is delivered by a multidisciplinary team but most commonly by social care practitioners.","Recommendations | Intermediate care including reablement | Guidance | NICE"]
[null,null,null,null,"Key components of post-diagnostic support for people with dementia and their carers I NIHR "]
[null,{"$f":"'4a. Supporting well'!B8","v":"4.2a"},"Non-pharmacological interventions are delivered in line with the NICE dementia guideline","The NICE guideline for dementia [NG97] outline a range of interventions to promote cognition, independence and wellbeing, which include cognitive stimulation therapy, reminiscence therapy and occupation therapy, as well as outlining interventions that should not be offered.  Commissioners should ensure a range of suitable interventions are commissioned and delivered, in line with the needs of the population and a person's preferences. \nIn add NICE Quality statement 6 (QS184) recognises that people with dementia can become distressed, which can lead to symptoms such as increased aggression, anxiety, apathy, agitation, depression, delusions, hallucinations and sleep disturbances. But these behaviours may have other causes, including pain, delirium or inappropriate care. Understanding the causes of these behaviours and addressing them before offering treatment can prevent things getting worse and prevent any harm. It can also avoid the use of unnecessary interventions, such as antipsychotic medication and antidepressants, which may not manage the symptoms effectively.","Interventions to promote cognition, independence and wellbeing I Recommendations I NG97 I Guidance I NICE"]
[null,null,null,null,"Managing distress I Quality statement 6 I QS184 I Guidance I NICE"]
[null,{"$f":"'4a. Supporting well'!B9","v":"4.3a"},"People with dementia have a structured assessment before starting non-pharmacological or pharmacological treatment for distress","The structured assessment is a requirement within the NICE Quality Standards for dementia QS184 (Standard 6) and should take place before starting pharmacological or non-pharmacological treatments. It should explore possible reasons for the person's distress, whilst assessing and addressing clinical or environmental causes (for example pain, delirium or inappropriate care).\nA trauma-informed approach should be taken as distress may stem from past experiences, not just clinical/ environmental factors.\n\nNICE Guidance NG97 recommends that when using antipsychotic medications the lowest effective should be used for the shortest possible time and should be reassessed at least every 6 weeks, to check whether the need for the medication is unchanged.","NICE Quality Standard QS184 | NICE"]
[null,null,null,null,"Coping with distress I Dementia UK "]
[null,{"$f":"'4a. Supporting well'!B10","v":"4.4a"},"People with dementia have discussed and documented an advance decision about future emergency care","The Universal Principles for Advance Care Planning (2022) state that:\nAdvance care planning is a voluntary process of person-centred discussion between an individual and their care providers about their preferences and priorities for their future care, while they have the mental capacity for meaningful conversation about these. The process, which is likely to involve a number of conversations over time, must have due consideration and respect for the person’s wishes and emotions at all times. As a result, the person should experience a greater sense of involvement and the opportunity to reflect and share what matters most to them.\nAdvance Care Planning discussions can occur over time, between people and those important to them, such as family, friends, people in their communities as well as with health and care professionals. It should not be assumed that everyone wants to \nhave ACP conversations when offered. Their wishes should be respected. If people decline, this can be sensitively revisited at a later date.","Universal Principles for Advance Care Planning (ACP) I NHS England"]
[null,null,null,null,"Advance care planning I Quality Standard 3 I QS184 I Guidance I NICE"]
[null,{"$f":"'4a. Supporting well'!B11","v":"4.5a"},"Structured medication reviews are undertaken post diagnosis at regular intervals by Primary Care","Medicines management and use of structured medication reviews for high-risk cohorts is a key requirement of PCNs. High-risk cohorts include those in care homes, with complex and problematic polypharmacy and those with severe frailty who have experienced recent hospital admissions and / or falls.\n\nParticular attention should be paid to high risk medicines such as anticholinergics, antipsychotics and benzodiazepines as well as any medications whose side effects are linked to an increased risk of falls.","Structured medication reviews - Primary Care | NHSE"]
[null,{"$f":"'4a. Supporting well'!B12","v":"4.6a"},"Observational tools are used for assessing pain in people living with dementia","The use of observational tools is important as people with dementia can express pain differently to other patient groups. This approach to pain assessment and management should be used consistently across sectors. Appropriate validated tools should be used when assessing, such as the Pain in Advanced Dementia (PAINAD) and Doloplus-2 scales.","Pain and dementia I Dementia UK"]
[null,null,null,null,"The assessment of pain in older people: UK national guidance | National Library of Medicine | NCIB"]
[null,{"$f":"'4a. Supporting well'!B13","v":"Supportive care"}]
[null,{"$f":"'4a. Supporting well'!B14","v":"4.7a"},"Care providers support people living with dementia by making dementia-friendly, person-centred activities available and supporting engagement  ","Ensuring people living with dementia can access appropriate activities needs to be personalised both to the person's interests and to their home environment.  For example, for those living in sheltered accommodation, professional carers should be proactive in enabling access to communal areas to facilitate involvement in activities available. Where people with dementia are living at home, professional carers should be aware of community activities and services available and facilitating access to these (such as a Befriending Service, for example). ","Recommendations | NG32 | Older people: independence and mental wellbeing | Guidance | NICE"]
[null,{"$f":"'4a. Supporting well'!B15","v":"4.8a"},"There is a standardised approach to care provider package assessments which incorporates input from the person living with dementia, their carers and the wider MDT","Due to its recognised link with dementia, it is important to recognise frailty in individuals as they move towards older age in order to get people the right help at the right time. When frailty is noticed, and a care requirement has been identified, systems should ensure that there is equity of access to care package assessments which is based on need, not social or financial circumstances.  ","Frailty and dementia | Dementia UK"]
[null,{"$f":"'4a. Supporting well'!B16","v":"4.9a"},"Care providers regularly review home-based packages of care following initial set up","Local authorities have a duty to undertake care and support plan reviews on a regular basis. Care reviews are usually carried out by a social worker or assessor from the local authority. There should be an initial review and subsequent regular review. This review process should be monitored / audited on a regular basis. ","Guidance: Care and support plans | NHSE"]
[null,{"$f":"'4a. Supporting well'!B17","v":"Communication "}]
[null,{"$f":"'4a. Supporting well'!B18","v":"4.10a"},"Written and verbal communications are accessible in multiple languages and for those who are visually or hearing impaired ","General Medical Council guidance states that all possible efforts must be made to ensure effective communication with patients. This includes arrangements to meet patients’ communication needs in languages other than English. Where language is a problem in discussing health matters, national guidance states that a professional interpreter is a legal right and should always be offered, rather than using family or friends to interpret. It is therefore vital that there are multilingual and/or BSL interpretation services available to enable good communication between staff and the patient and their carers/family.   ","Communicating with someone with dementia | NHSE"]
[null,{"$f":"'4a. Supporting well'!B19","v":"4.11a"},"Communication aids are used to support communication with people living with dementia","Communication aids are often called augmentative or alternative communication aids or AAC. These could include: \n\n- charts with pictures, symbols, letters or words\n- simple single message voice output devices\n- applications that run on tablets and mobile phones\n\nIn addition visual timetables where photos or images are used to show what will happen at various times can support a person with dementia to understand and to communicate more easily.","Communication aids : NI Direct "]
[null,"Pillar 4b: Supporting Well in Hospital\nThere is access to safe high quality health and social care for people living with dementia and their carers "]
[null,{"$f":"'4b. Supporting well'!B6","v":"Emergency Department "}]
[null,{"$f":"'4b. Supporting well'!B7","v":"4.1b"},"Adaptations are in place to accommodate the needs of people with dementia while in the Emergency Department","Hospital staff should have the means to identify people who have dementia or suspected dementia as quickly as possible and fast-track their assessment, making reasonable adjustments as required, to help avoid distressing waits in a dementia-unfriendly environment. In addition, the identification of frailty and its severity is an important factor for those patients who are also diagnosed with dementia.  Acute frailty services have the knowledge and skills to further assess and support those who are living with frailty including those who are diagnosed with dementia, as per the FRAIL strategy. Admission pathways should be designed so people with dementia do not have to wait for long periods of time in potentially traumatising Emergency Department environments and to ensure that they get a timely, comprehensive assessment of their needs.","FRAIL Strategy | NHSE"]
[null,null,null,null,"Change area C I High Impact Change I LGA"]
[null,{"$f":"'4b. Supporting well'!B8","v":"Admission "}]
[null,{"$f":"'4b. Supporting well'!B9","v":"4.2b"},"Clinical teams have access to a dementia specialist for advice, patient review, and to facilitate good communication with people living with dementia and their carers","The dementia specialist could be a neurologist, psychiatrist, specialist dementia nurse or AHP. The dementia specialist facilitates good communication with carers / family and, in complex cases, may be asked to follow the patient throughout their inpatient journey. Hospitals should have robust systems and mechanisms in place to identify patients with dementia so that this support is made available to them.   The person with dementia and their carer and/or family members should be made aware from admission who the named dementia specialist is, and how to access their support if needed.","Case studies I High Impact Change I LGA"]
[null,{"$f":"'4b. Supporting well'!B10","v":"4.3b"},"On admission, the person living with dementia, and their families and carers, are informed of the named clinician responsible for their care and how to access them during the hospital stay ","The name of the responsible clinician should be documented in patient notes on admission. The person with dementia and their carer and/or family members should be made aware from admission who the named clinician responsible for the patient's care is, and how to access them if needed."]
[null,{"$f":"'4b. Supporting well'!B11","v":"4.4b"},"Community care co-ordinators and professionals involved in care at home are contacted to make them aware of admission into hospital","Hospital protocols should include a named professional that is responsible for carrying out this action on admission, for example a nurse or social worker. Contact should continue from admission to discharge.\nThe NICE guideline and quality standard on transition between inpatient hospital settings and community or care home settings states that adults with social care needs who are in hospital should have a named discharge coordinator to ensure a safe and planned discharge from hospital. The national audit of dementia reported that, in 2018/19, 92% of hospitals had a named person in place to co-ordinate discharge plans for people with dementia. Having a named discharge coordinator helps to ensure a safe and planned discharge from hospital.","NICE Impact Dementia I Impact of our guidance I NICE"]
[null,{"$f":"'4b. Supporting well'!B12","v":"Inpatient stay "}]
[null,{"$f":"'4b. Supporting well'!B13","v":"4.5b"},"Delirium screening is undertaken using a structured screening tool, such as 4AT","Structured screening tools such as the 4AT standardise the approach to the diagnosis of delirium and, in the case of the 4AT, measures alertness, awareness, attention, and acute change or fluctuating course. Screening tools should be complemented by carer/family input to capture a pre-hospital cognitive baseline. Use of these tools also support a wider Frailty assessment, where appropriate, as indicated within the NHS England FRAIL Strategy. \n\nPositive screening for delirium should be followed up with appropriate treatment plans and increased monitoring of the patient. The diagnosis should be factored into discharge planning activities. ","Assessment | Diagnosis | Delirium | CKS | NICE"]
[null,null,null,null,"Delirium - symptoms, diagnosis and treatment | Alzheimer's Society"]
[null,{"$f":"'4b. Supporting well'!B14","v":"4.6b"},"Carers are welcomed and supported during a hospital admission, in line with John's Campaign","John's Campaign is a call to action to highlight and acknowledge the importance of carers in health and care settings. Carers UK has been developing a scheme to raise the profile of carers through the Carer Passport initiative. A Carer  Passport is a record that identifies a carer in some way and sets out an offer of support, services or other benefits in response. Having a Carer Passport scheme in the organisation can: increase identification and support for carers; raise awareness of caring; provide a concrete, easily understandable offer of support or services; make carers feel valued; help organisations benefit from carer involvement. Hospitals may provide benefits for carers such as reduced parking and refreshment costs as well as shared care arrangements between carers. ","John's Campaign"]
[null,null,null,null,"Carers' Passport Scheme | Carers UK "]
[null,{"$f":"'4b. Supporting well'!B15","v":"4.7b"},"Inpatient ward environments are designed in ways that meet the needs of people living with dementia","The physical environment within a hospital can have a significant impact on the cognitive function, recovery and distress levels of a person living with dementia. The ‘DHSC Dementia-friendly Health and Social care Environment Health Building Note’ (2015)42 provides guidance on design principles, which include:\n- environments that are safe, secure and easy to move around, so that they are to make the best of their remaining abilities\n- providing optimum levels of stimulation, \n- considerations around lighting and contrast ","Dementia-friendly Health and Social Care Environments | DHSC"]
[null,null,null,null,"A specialist ward for people with dementia | Alzheimer's Society"]
[null,{"$f":"'4b. Supporting well'!B16","v":"4.8b"},"Medication reviews are undertaken during the inpatient stay","In line with the CQC Regulation 12: Safe care and treatment, medication reviews must be part of, and align with, people's care and treatment assessments, plans or pathways and should be completed and reviewed regularly when their medication changes. Particular attention should be given to high risk medicines such as anticholinergics, antipsychotics and benzodiazepines as well as any medicine with side effects that can result in falls and should ensure person-centred deprescribing conversations, not just routine medication reviews. Communication on discharge letters should include information about changes to medication whilst in hospital.","Polypharmacy in older people: A guide for healthcare professionals | NHS Wales"]
[null,null,null,null,"Regulation 12: Safe care and treatment | CQC"]
[null,{"$f":"'4b. Supporting well'!B17","v":"4.9b"},"Risks associated with frailty and dementia are monitored during an inpatient stay, such as malnutrition, dehydration and falls","Inpatients with dementia may require additional support with hydration and nutrition due to the memory loss aspect of their cognitive impairment and are at higher risk of becoming malnourished and dehydrated. A Nutrition and Hydration Chart should used to monitor the risk of dehydration and malnutrition. Referrals should be made to Dietician and Speech and Language Therapy for patients experiencing poor nutritional intake or swallowing difficulties. Documented discussions should be held with the person living with dementia and their carers/families regarding nutritional preferences. Hospitals should adhere to the CQC Regulation 14: Meeting nutritional and hydration needs. \n\nPeople with dementia are also at higher risk of falls due to problems with mobility, balance and muscle weakness, as well as challenges with memory, recognition and visual processing.  Falls assessment tools can be used to assess and reduce the risk, considering any environmental adaptations that may be required during a hospital stay.  ","Regulation 14: Meeting nutritional and hydration needs | CQC"]
[null,{"$f":"'4b. Supporting well'!B18","v":"4.10b"},"During an acute admission to hospital, people experiencing dementia have the opportunity to review and revise their advance care plan ","The Universal Principles for Advance Care Planning (2022) state that:\nAdvance care planning is a voluntary process of person-centred discussion between an individual and their care providers about their preferences and priorities for their future care, while they have the mental capacity for meaningful conversation about these. The process, which is likely to involve a number of conversations over time, must have due consideration and respect for the person’s wishes and emotions at all times. As a result, the person should experience a greater sense of involvement and the opportunity to reflect and share what matters most to them.\n\nThe outputs of these discussions may include one or more of the following: \n• An advance statement – of wishes, preferences and priorities, and may include nomination of a named spokesperson \n• An Advance Decision to Refuse Treatment (ADRT) \n• Nomination of a Lasting Power of Attorney (LPA) for health and welfare who is legally empowered to make decisions up to, or including, life sustaining treatment on behalf of the person if they do not have mental capacity at the time, depending on the level of authority granted by the person.\n• Context-specific treatment recommendations such as emergency care and treatment plans, treatment escalation plans, cardiopulmonary resuscitation decisions, etc.","ReSPECT Guidance | Resuscitation Council UK  \n"]
[null,null,null,null,"Universal Principles for Advance Care Planning (ACP) I NHS England"]
[null,{"$f":"'4b. Supporting well'!B19","v":"4.11b"},"There are person-centred, dementia inclusive activities available and an activities coordinator actively engages with inpatients living with dementia ","Individualised activities should be offered, alongside group activities, and can include examples such as playing music, having objects to touch and interact with, and hand massage.","Recommendations | Older people: independence and mental wellbeing | Guidance | NICE"]
[null,{"$f":"'4b. Supporting well'!B20","v":"Communication "}]
[null,{"$f":"'4b. Supporting well'!B21","v":"4.12b"},"Written and verbal communications are accessible in multiple languages and for those who are visually or hearing impaired ","General Medical Council guidance states that all possible efforts must be made to ensure effective communication with patients. This includes arrangements to meet patients’ communication needs in languages other than English. Where language is a problem in discussing health matters, national guidance states that a professional interpreter is a legal right and should always be offered, rather than using family or friends to interpret. It is therefore vital that there are multilingual and/or BSL interpretation services available to enable good communication between hospital staff and the patient and their carers/family.   ","Language interpretation migrant health guide | Gov.UK"]
[null,{"$f":"'4b. Supporting well'!B22","v":"4.13b"},"Communication aids are used to support communication with people living with dementia","Communication aids are often called augmentative or alternative communication aids or AAC. These could include: \n\n- charts with pictures, symbols, letters or words\n- simple single message voice output devices\n- applications that run on tablets and mobile phones\n\nIn addition visual timetables where photos or images are used to show what will happen at various times can support a person with dementia to understand and to communicate more easily.","Communication aids : NI Direct "]
[null,{"$f":"'4b. Supporting well'!B23","v":"Mental capacity and safeguarding"}]
[null,{"$f":"'4b. Supporting well'!B24","v":"4.14b"},"All hospital staff are trained in how to raise a safeguarding concern, with specific awareness on people living with dementia ","All providers must make sure that they have robust procedures and processes that make sure that safeguarding concerns can be raised and escalated. As part of their induction, staff must receive safeguarding training that is relevant, and at a suitable level for their role. Training should be updated at appropriate intervals and should keep staff up to date and enable them to recognise different types of abuse and the ways they can report concerns. Staff must be aware of their individual responsibilities to prevent, identify and report abuse while providing care and treatment.","Safeguarding and Dementia | Alzheimer's Society"]
[null,{"$f":"'4b. Supporting well'!B25","v":"4.15b"},"A mental capacity assessment is undertaken and a Deprivation of Liberty Safeguards document and / or Mental Health Assessment is completed for all inpatients who lack mental capacity without clinical rationale","Providers must understand and work within the legal framework of the Mental Capacity Act 2005 whenever they work with people who may lack the mental capacity to make some decisions. The law applies to situations where someone is unable to make a specific decision at a particular time because of the way their mind or brain is affected.","Mental Capacity Act | NHS"]
[null,null,null,null,"Regulation 13: Safeguarding service users from abuse | CQC"]
[null,{"$f":"'4b. Supporting well'!B26","v":"4.16b"},"There is a procedure in place for Deprivation of Liberty to be completed out of hours ","Where a person lacks mental capacity to consent to arrangements that deprive them of their liberty, providers must follow the current legal framework under the Mental Capacity Act 2005. This currently includes the Deprivation of Liberty Safeguards (DoLS) for care home and hospital settings.  The policy associated with DOLS should ensure staff are able to act outside of standard working hours.","Mental Capacity Act | NHS"]
[null,null,null,null,"Regulation 13: Safeguarding service users from abuse | CQC"]
[null,{"$f":"'4b. Supporting well'!B27","v":"Discharge"}]
[null,{"$f":"'4b. Supporting well'!B28","v":"4.17b"},"Discharge planning is started at the point of admission, or before elective procedures, with mechanisms available to involve the multi-disciplinary team, as required","Research suggests that undertaking early planning reduces delays to discharge. The admitting nurse should begin discharge planning and look to involve MDT input at the earliest opportunity. MDT meetings should involve carers and families where applicable following a discussion with the person living with dementia about who should be included in the conversations.\nPrehabilitation may also support effective discharge planning, reducing the risk of complications and non-home discharge.\nThe 'High Impact Change Model: Improving the timely and effective discharge of people with dementia and delirium into the community' provides guidance on achieving an optimised discharge process.","Principle 1: Plan for discharge from the start | NHSE"]
[null,null,null,null,"Change area F I High Impact Change I LGA"]
[null,{"$f":"'4b. Supporting well'!B29","v":"4.18b"},"Patients living with dementia, their carers and families are supported with relevant information on discharge, including as a minimum, a copy of the discharge summary, with details of medication and any future appointments","People living with dementia and their carers are supported with relevant information on discharge, including as a minimum, a copy of the discharge summary, with details of medication and any future appointments.\n\nStatutory guidance on Hospital discharge and community support states that discharge planning should include information about post-discharge care, such as advice and information about voluntary and community sector organisations, housing options and NHS and/or social care crisis response teams that can be contacted if needed.","Hospital Discharge and Community Support Guidance | DHSC "]
[null,{"$f":"'4b. Supporting well'!B30","v":"4.19b"},"There are clear and standardised pathways for appropriate referrals from hospital to dementia diagnostic service providers","Direct referrals from secondary care settings to dementia specialist diagnostic services help to ensure that assessment and diagnosis happen in a timely and accurate way through a standardised referral to treatment pathway.  This involves ensuring direct pathways are both commissioned and adhered to.","Referral, Diagnosis, and Care Planning | NICE"]
[null,"Pillar 5: Living Well\nPeople with dementia can live well in safe and accepting communities"]
[null,{"$f":"'5. Living well'!B5","v":"Inclusive environments  "}]
[null,{"$f":"'5. Living well'!B6","v":5.0999999999999996},"Local authorities have policies in place to ensure their neighbourhoods are safe and welcoming for people living with dementia","The Alzheimer's Society defines a dementia-friendly community as a city, town or village where people with dementia are understood, respected and supported by organisations in their local environment.  The Neighbourhood Health model aims to create healthier communities, helping people of all ages live healthy, active and independent lives for as long as possible while improving their experience of health and social care, and increasing their agency in managing their own care.","What is a dementia-friendly community? | Alzheimer's Society "]
[null,{"$f":"'5. Living well'!B7","v":5.2},"Local authorities have plans and policies in place to improve the accessibility of the physical environment for people living with dementia ","Plans and policies in place to improve the accessibility of the physical environment for people living with dementia may include housing, transport, natural and urban spaces, and architectural planning. Other considerations could include accessible public facilities and clear signage.","Dementia friendly communities: guidance for councils | Local Gov UK"]
[null,{"$f":"'5. Living well'!B8","v":5.3},"Community events and activities that promote wellbeing are organised, and held regularly, in response to feedback from people living with dementia and their carers ","Mechanisms should be in place to ensure that feedback sought from people affected by dementia is used to help guide the organisation of community events and activities.","Lived Experience Advisory Panel | Dementia UK"]
[null,{"$f":"'5. Living well'!B9","v":5.4},"Community events and activities are accessible for people living with dementia and their carers","Neighbourhoods and communities should ensure that activities and events consider accessibility and inclusivity requirements for people living with dementia.  The UK Network of Dementia Voices provides useful checklists that consider a range of factors including how easy venues are to get to, how easy it is to move around, specific considerations around toilets, flooring and lighting, along with whether environments are calming and safe.  Guidance is also available for outdoor spaces.","Making Things More Accessible | Dementia Voices"]
[null,{"$f":"'5. Living well'!B10","v":"Urgent neighbourhood services"}]
[null,{"$f":"'5. Living well'!B11","v":5.5},"A range of suitable urgent community-based services are commissioned, including crisis prevention, urgent, and intensive support services","The Neighbourhood Health Guidelines emphasise how critical it is for integrated neighbourhoods to ensure urgent community response and hospital at home services are aligned to local demand and work together to deliver a co-ordinated service.\n\nCrisis prevention could include services such as an Intensive Support Team for Older People which delivers high quality, specialist assessments and interventions to people with dementia whose behaviour significantly challenges themselves and / or others. The team could consist of staff from a wide range of backgrounds including, for example, falls prevention teams, community nursing teams, psychology and occupational therapy. Services such as these can support in keeping people living with dementia in the place they live for as long as possible, receiving as much care, support and treatment as they can within the community.","A scoping review of crisis teams managing dementia in older people I NIHR"]
[null,null,null,null,"Neighbourhood health guidelines I NHSE"]
[null,{"$f":"'5. Living well'!B12","v":5.6},"Ambulance services have avenues for seeking advice when required and access to suitable alternative pathways to out of hospital services ","There should be clear protocols in place for gaining appropriate advice and making appropriate onward referrals. Advice avenues may include, for example, senior clinical advice from the ambulance control hub (advanced paramedic, doctor etc); various advice phone lines (depending on what is available locally) e.g. a frailty line to a hospital, falls referral team, mental health crisis team; GP services including out of hours GPs; virtual wards, and helplines provided by third sector organisations. Where out of hospital services are available, referral pathways should exist to support direct referral from the ambulance service. ","Change area B I High Impact Change I LGA"]
[null,{"$f":"'5. Living well'!B13","v":"Supporting carers"}]
[null,{"$f":"'5. Living well'!B14","v":5.7},"Advice is given to carers about their right to carer assessment, and accessibility to respite care, breaks, and support groups","Local authorities should have readily accessible lists of recommended local respite providers and should be proactive in the promoting and sharing of these lists with carer populations, GP practices, and social work departments. Local respite provider lists should include agencies for respite at home.\n\n'NICE Guidance [NG150]: Supporting adult carers' states that carers should be are kept regularly informed about available community services and other sources of support and advice and how to access them.","Carers' breaks and respite care | NHS"]
[null,null,null,null,"Peer Support: Sharing experiences in a safe and supportive environment | Alzheimer's Society"]
[null,{"$f":"'5. Living well'!B15","v":5.8},"Interventions for carers are evidence-based, appropriate, and tailored according to their age, ethnicity, religion, gender, and sexual orientation","NICE Guidance [NG150]: Supporting adult carers' outlines a range of interventions that should be made available for carers, including:\n- psychosocial and psychoeducational support\n- psychotherapy and counselling interventions\n- information and emotional and practical support to carers when their circumstances change\n\nIn addition, interventions might include cognitive behavioural therapy, breakaway training, housing and financial advice and support.","Overview | Supporting adult carers | Guidance | NICE"]
[null,null,null,null,"Quality statement 7: Supporting carers | Dementia | Quality standards | NICE"]
[null,"Pillar 6: Dying Well\nPeople living with dementia die well (End of Life & Palliative Care)"]
[null,{"$f":"'6. Dying Well'!B5","v":"Personalised support and care planning"}]
[null,{"$f":"'6. Dying Well'!B6","v":6.1},"Advance care plans are offered and recorded, in line with the person's wishes","The Universal Principles for Advance Care Planning (2022) state that:\n\nAdvance care planning is a voluntary process of person-centred discussion between an individual and their care providers about their preferences and priorities for their future care, while they have the mental capacity for meaningful conversation about these. The process, which is likely to involve a number of conversations over time, must have due consideration and respect for the person’s wishes and emotions at all times. As a result, the person should experience a greater sense of involvement and the opportunity to reflect and share what matters most to them.\nAdvance Care Planning discussions can occur over time, between people and those important to them, such as family, friends, people in their communities as well as with health and care professionals. It should not be assumed that everyone wants to \nhave ACP conversations when offered. Their wishes should be respected. If people decline, this can be sensitively revisited at a later date.","Universal Principles for Advance Care Planning (ACP) I NHS England"]
[null,{"$f":"'6. Dying Well'!B7","v":6.2},"A systematic, proactive approach is used to identify people living with dementia who are also likely to be in the last 12 months of life","NICE Quality Standard 13: End of life care for adults. Service providers (such as care homes, community care, mental health care, social care, primary care, secondary care and tertiary care) ensure that systems are in place and staff are trained to identify adults who are likely to be approaching the end of their life. Health and social care professionals should be equipped with the knowledge, skills and confidence to identify when a person with dementia is likely to be within the last 12 months of life.  Whilst it is accepted that this can be complex and challenging to achieve, a wide range of tools can be used to support this assessment, and identification can provide benefits in ensuring that the person living with dementia is receiving the best care possible. \nA wide range of tools are available to support the identification of people expected to be approaching the last 12 months of life, for example the Supportive Palliative Care Indicators Tool, the EARLY identification in palliative and end of life care tool, the Rockwood Frailty Scale, and the Prognostic Indicator Guidance. ","QS13 I Guidance I NICE"]
[null,null,null,null,"Early toolkit for primary care I Palliative and end of life care I NHSE"]
[null,{"$f":"'6. Dying Well'!B8","v":"Joined up care"}]
[null,{"$f":"'6. Dying Well'!B9","v":6.3},"People living with dementia who are also identified as likely to be in the last 12 months of life are added to the GP palliative care register","Following identification, people with a dementia diagnosis who are likely to be in the last 12 months of life should be added to the GP Palliative Care Register to enable coordinated care with continuity, with a discussion/review regarding the person’s wishes and preferences and a review of their care plan (advance care planning). \nIt is a contractual requirement for General Practice to maintain a robust palliative care register and to ensure information is captured and shared with partner agencies, in line with the 'Professional Record Standards Body' standard for Palliative and End of Life Care.\nOther factors to consider include the completion of an SR1 form for fast track access to relevant benefits.","Universal Principles for Advance Care Planning (ACP) I NHS England"]
[null,null,null,null,"PRSB Standards - PRSB"]
[null,{"$f":"'6. Dying Well'!B10","v":6.4},"People living with dementia are enabled to continue living at home, and to die there if that is their wish, through effective coordination and continuity of care delivery across services","NICE Clinical Knowledge Summary Scenario: Management of end-stage dementia states that: \nPeople with dementia may require coordination of a diverse range of services (for example primary care, community nursing, physiotherapy, and hospice care) to enable them to continue living at home and to die there if that is their wish.","Management of end stage dementia I Management I Dementia I CKS I NICE"]
[null,{"$f":"'6. Dying Well'!B11","v":6.5},"Integrated multidisciplinary approaches are taken to the delivery of palliative care and end of life care for people living with dementia","The Statutory Guidance for Integrated Care Boards states that high quality Palliative Care and End of Life Care requires multi-disciplinary teams to work collaboratively across health and care, including with VCSE high-quality partners. \nNHS England’s Neighbourhood Health Guidelines 2025/26 make highlight adults with moderate or severe frailty (physical frailty or cognitive frailty, for example, dementia) and people of all ages with palliative care or end of life care needs as priority cohorts for this way of working.","Palliative and End of Life Care Statutory Guidance for ICBs I NHSE"]
[null,{"$f":"'6. Dying Well'!B12","v":6.6},"People living with dementia have equity of access to timely specialist palliative care, as required","During the advanced stages of dementia, care should be available in a variety of settings, including at home, in a care home, in hospital and in a hospice. Palliative care teams should consider the person’s wishes, wherever possible, including any preferences recorded in an Advance Care Plan.\nPeople’s palliative and end of life care needs, and complexity of their needs, will fluctuate, and this means that a flexible model of care is required. No single provider can provide for all needs and people will require access to a wide variety of non-specialist palliative care delivered by primary, community, acute and urgent care services, and social care. Some people will also require support, advice and consultation from specialist-level palliative care services.","End-of-life care at home I Dementia and end of life planning I NHSE"]
[null,{"$f":"'6. Dying Well'!B13","v":"Knowledge and skills"}]
[null,{"$f":"'6. Dying Well'!B14","v":6.7},"Health and care professionals have the knowledge, skills, and confidence to undertake effective advance care planning conversations","Health and social care providers should provide access to and allow time for health and care professionals to access advance care planning and communication training. This will support health and care workers involved in the advance care planning conversation to be prepared with information the person may need or want to help them make informed decisions. It will also provide the opportunity to promote living well, as well as improving the quality of conversations and understanding about health, illness, death and dying.\nPlanning for future care can help patients and families / carers to feel more confident that their wishes will be considered if they are ever unable to fully participate in decision making. By having good quality conversations about future treatment, people have a greater sense of control over their ability to live and die well. The outputs of these discussions may include one or more of the following: \n• An advance statement – of wishes, preferences and priorities, and may include nomination of a named spokesperson \n• An Advance Decision to Refuse Treatment (ADRT) \n• Nomination of a Lasting Power of Attorney (LPA) for health and welfare who is legally empowered to make decisions up to, or including, life sustaining treatment on behalf of the person if they do not have mental capacity at the time, depending on the level of authority granted by the person. • Context-specific treatment recommendations such as emergency care and treatment plans, treatment escalation plans, cardiopulmonary resuscitation decisions, etc.","Ambitions for palliative and end of life care I National Palliative and End of Life Care Partnership"]
[null,{"$f":"'6. Dying Well'!B15","v":6.8},"Health and social care professionals have the knowledge, skills and confidence to provide high quality palliative care and end of life care to people living with dementia","Integrated care boards and providers should consider the education, training, and professional development workforce to enable delivery of high quality palliative care and end of life care for people living with dementia.","Palliative and End of Life Care Statutory Guidance for ICBs I NHSE"]

{"sheet":"Dashboard","index":10,"n_rows":28,"n_cols":13,"rows_kept":28,"cut":false,"hidden":false,"merged":[[1,1,1,13],[2,1,2,13],[4,4,4,12],[4,2,4,3]]}
[]
[null,"Dementia 100: Dashboard"]
[null,"Overall summary by pillar and level"]
[]
[null,null,"Dementia 100: Pathway Assessment Tool for: ",null,{"$f":"IF(Title!$D$8=\"Complete Place or ICB area here\",\"Please complete your Place or ICB area name on the Title sheet\",Title!$D$8)","v":"Please complete your Place or ICB area name on the Title sheet"}]
[]
[null,null,null,"Awaiting Score","Level 0","Level 1","Level 2","Level 3","Level 4","Level 5",null,"Total Completed","Completion %"]
[null,null,"Pillar 1: Leading Well",{"$f":"COUNTIF('Improvement Plan'!$D$12:$D$37,\"\")","v":26},{"$f":"COUNTIF('Improvement Plan'!$D$12:$D$37,Dashboard!E$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$12:$D$37,Dashboard!F$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$12:$D$37,Dashboard!G$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$12:$D$37,Dashboard!H$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$12:$D$37,Dashboard!I$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$12:$D$37,Dashboard!J$7)","v":0},null,{"$f":"SUM($E8:$J8)","v":0},{"$f":"IFERROR(L8/(SUM(D8:J8)),\"\")","v":0}]
[null,null,"Pillar 2: Preventing Well",{"$f":"COUNTIF('Improvement Plan'!$D$39:$D$47,\"\")","v":9},{"$f":"COUNTIF('Improvement Plan'!$D$39:$D$47,Dashboard!E$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$39:$D$47,Dashboard!F$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$39:$D$47,Dashboard!G$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$39:$D$47,Dashboard!H$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$39:$D$47,Dashboard!I$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$39:$D$47,Dashboard!J$7)","v":0},null,0,{"$f":"IFERROR(L9/(SUM(D9:J9)),\"\")","v":0}]
[null,null,"Pillar 3: Diagnosing Well",{"$f":"COUNTIF('Improvement Plan'!$D$49:$D$67,\"\")","v":19},{"$f":"COUNTIF('Improvement Plan'!$D$49:$D$67,Dashboard!E$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$49:$D$67,Dashboard!F$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$49:$D$67,Dashboard!G$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$49:$D$67,Dashboard!H$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$49:$D$67,Dashboard!I$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$49:$D$67,Dashboard!J$7)","v":0},null,0,0]
[null,null,"Pillar 4a: Supporting Well in the Community",{"$f":"COUNTIF('Improvement Plan'!$D$69:$D$79,\"\")","v":11},{"$f":"COUNTIF('Improvement Plan'!$D$69:$D$79,Dashboard!E$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$69:$D$79,Dashboard!F$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$69:$D$79,Dashboard!G$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$69:$D$79,Dashboard!H$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$69:$D$79,Dashboard!I$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$69:$D$79,Dashboard!J$7)","v":0},null,0,0]
[null,null,"Pillar 4b: Supporting Well in Hospital",{"$f":"COUNTIF('Improvement Plan'!$D$81:$D$99,\"\")","v":19},{"$f":"COUNTIF('Improvement Plan'!$D$81:$D$99,Dashboard!E$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$81:$D$99,Dashboard!F$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$81:$D$99,Dashboard!G$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$81:$D$99,Dashboard!H$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$81:$D$99,Dashboard!I$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$81:$D$99,Dashboard!J$7)","v":0},null,0,0]
[null,null,"Pillar 5: Living Well",{"$f":"COUNTIF('Improvement Plan'!$D$101:$D$108,\"\")","v":8},{"$f":"COUNTIF('Improvement Plan'!$D$101:$D$108,Dashboard!E$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$101:$D$108,Dashboard!F$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$101:$D$108,Dashboard!G$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$101:$D$108,Dashboard!H$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$101:$D$108,Dashboard!I$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$101:$D$108,Dashboard!J$7)","v":0},null,0,0]
[null,null,"Pillar 6: Dying Well",{"$f":"COUNTIF('Improvement Plan'!$D$110:$D$117,\"\")","v":8},{"$f":"COUNTIF('Improvement Plan'!$D$110:$D$117,Dashboard!E$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$110:$D$117,Dashboard!F$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$110:$D$117,Dashboard!G$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$110:$D$117,Dashboard!H$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$110:$D$117,Dashboard!I$7)","v":0},{"$f":"COUNTIF('Improvement Plan'!$D$110:$D$117,Dashboard!J$7)","v":0},null,0,0]
[]
[null,null,"Total",{"$f":"SUM(D8:D14)","v":100},0,0,0,0,0,0,null,{"$f":"SUM(L8:L14)","v":0},0]
[null,null,"Total %",{"$f":"IFERROR(D16/(SUM($D$8:$J$14)),\"\")","v":1},{"$f":"IFERROR(E16/(SUM($D$8:$J$14)),\"\")","v":0},0,0,0,0,0]
[]
[null,null,"Improvement Priorities"]
[]
[null,null,"Total number of National Priorities",{"$f":"COUNTIF('Improvement Plan'!$E:$E, \"National Priority\")","v":14}]
[null,null,"Total number of Local Priorities",{"$f":"COUNTIF('Improvement Plan'!$E:$E, \"Local Priority\")","v":0}]
[]
[null,null,null,"Awaiting Score","Level 0","Level 1","Level 2","Level 3","Level 4","Level 5",null,"Total Completed","Completion %"]
[null,null,"National Priorities",{"$f":"COUNTIFS('Improvement Plan'!$E:$E,\"National Priority\",'Improvement Plan'!$D:$D,\"\")","v":14},{"$f":"COUNTIFS('Improvement Plan'!$E:$E,\"National Priority\",'Improvement Plan'!$D:$D,Dashboard!E$7)","v":0},{"$f":"COUNTIFS('Improvement Plan'!$E:$E,\"National Priority\",'Improvement Plan'!$D:$D,Dashboard!F$7)","v":0},{"$f":"COUNTIFS('Improvement Plan'!$E:$E,\"National Priority\",'Improvement Plan'!$D:$D,Dashboard!G$7)","v":0},{"$f":"COUNTIFS('Improvement Plan'!$E:$E,\"National Priority\",'Improvement Plan'!$D:$D,Dashboard!H$7)","v":0},{"$f":"COUNTIFS('Improvement Plan'!$E:$E,\"National Priority\",'Improvement Plan'!$D:$D,Dashboard!I$7)","v":0},{"$f":"COUNTIFS('Improvement Plan'!$E:$E,\"National Priority\",'Improvement Plan'!$D:$D,Dashboard!J$7)","v":0},null,{"$f":"SUM($E25:$J25)","v":0},{"$f":"IFERROR(L25/(SUM(D25:J25)),\"\")","v":0}]
[null,null,"Local Priorities",{"$f":"COUNTIFS('Improvement Plan'!$E:$E,\"Local Priority\",'Improvement Plan'!$D:$D,\"\")","v":0},{"$f":"COUNTIFS('Improvement Plan'!$E:$E,\"Local Priority\",'Improvement Plan'!$D:$D,Dashboard!E$7)","v":0},{"$f":"COUNTIFS('Improvement Plan'!$E:$E,\"Local Priority\",'Improvement Plan'!$D:$D,Dashboard!F$7)","v":0},{"$f":"COUNTIFS('Improvement Plan'!$E:$E,\"Local Priority\",'Improvement Plan'!$D:$D,Dashboard!G$7)","v":0},{"$f":"COUNTIFS('Improvement Plan'!$E:$E,\"Local Priority\",'Improvement Plan'!$D:$D,Dashboard!H$7)","v":0},{"$f":"COUNTIFS('Improvement Plan'!$E:$E,\"Local Priority\",'Improvement Plan'!$D:$D,Dashboard!I$7)","v":0},{"$f":"COUNTIFS('Improvement Plan'!$E:$E,\"Local Priority\",'Improvement Plan'!$D:$D,Dashboard!J$7)","v":0},null,{"$f":"SUM($E26:$J26)","v":0},""]
[]
[null,null,null,{"$f":"SUM(D25:D26)","v":14},0,0,0,0,0,0,null,{"$f":"SUM(L25:L26)","v":0},{"$f":"IFERROR(L28/(SUM(D28:J28)),\"\")","v":0}]

{"sheet":"Improvement Plan","index":11,"n_rows":117,"n_cols":8,"rows_kept":117,"cut":false,"hidden":false,"merged":[[99,1,99,7],[108,1,108,7],[1,1,1,7],[2,1,2,7],[7,1,7,7],[4,1,4,2],[4,3,4,7],[10,1,10,7],[37,1,37,7],[47,1,47,7],[67,1,67,7],[79,1,79,7]]}
[]
[null,"Dementia 100: Improvement Plan"]
[null,"Actions identified as Improvement Priorities will appear in the table below"]
[]
[null,"Dementia 100: Pathway Assessment Tool for: ",null,{"$f":"IF(Title!$D$8=\"Complete Place or ICB area here\",\"Please complete your Place or ICB area name on the Title sheet\",Title!$D$8)","v":"Please complete your Place or ICB area name on the Title sheet"}]
[]
[]
[null,"The table below brings together all 100 criteria, drawing information from across the Pillars tabs to highlight your achievement levels and those criteria you have selected as local and national priorities. For all priority areas please identify the actions you will take, a target date for completion of the actions and a person who is responsible for the action.  The table can also be used to extract all 100 criteria levels to be compared at an ICB level."]
[]
[null,"Ref","Criteria Desc","Level Selected","Local or National Priority?","Actions","Target Date","Responsible Individual\n(Name & Role)"]
[null,"Pillar 1: Leading Well"]
[null,{"$f":"'1. Leading well'!B6","v":1.1000000000000001},{"$f":"'1. Leading well'!C6","v":"There are mechanisms in place to ensure providers are engaging in research activities, including established links with the Research Delivery Network and the recruitment of Research Champions"},{"$f":"IF('1. Leading well'!D6=\"\",\"\",'1. Leading well'!D6)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F6),\"No\",'1. Leading well'!F6)","v":"No"}]
[null,{"$f":"'1. Leading well'!B7","v":1.2},{"$f":"'1. Leading well'!C7","v":"There are robust processes in place to ensure research evidence and NICE guideline updates are implemented in practice"},{"$f":"IF('1. Leading well'!D7=\"\",\"\",'1. Leading well'!D7)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F7),\"No\",'1. Leading well'!F7)","v":"No"}]
[null,{"$f":"'1. Leading well'!B9","v":1.3},{"$f":"'1. Leading well'!C9","v":"Service developments and quality improvement plans are driven by clinical data and outcomes, reviewed collaboratively across the system"},{"$f":"IF('1. Leading well'!D9=\"\",\"\",'1. Leading well'!D9)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F9),\"No\",'1. Leading well'!F9)","v":"No"}]
[null,{"$f":"'1. Leading well'!B10","v":1.4},{"$f":"'1. Leading well'!C10","v":"Data sharing agreements are in place for the purposes of system-wide reporting and improvement  "},{"$f":"IF('1. Leading well'!D10=\"\",\"\",'1. Leading well'!D10)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F10),\"No\",'1. Leading well'!F10)","v":"No"}]
[null,{"$f":"'1. Leading well'!B11","v":1.5},{"$f":"'1. Leading well'!C11","v":"There are mechanisms in place to facilitate the accurate coding of patients diagnosed with dementia in General Practice"},{"$f":"IF('1. Leading well'!D11=\"\",\"\",'1. Leading well'!D11)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F11),\"No\",'1. Leading well'!F11)","v":"No"}]
[null,{"$f":"'1. Leading well'!B12","v":1.6},{"$f":"'1. Leading well'!C12","v":"Shared electronic patient records are used by multiple agencies to navigate complex pathways "},{"$f":"IF('1. Leading well'!D12=\"\",\"\",'1. Leading well'!D12)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F12),\"No\",'1. Leading well'!F12)","v":"No"}]
[null,{"$f":"'1. Leading well'!B14","v":1.7},{"$f":"'1. Leading well'!C14","v":"People living with dementia and their carers are regularly asked about what is going well and what requires improvement to inform the development of local services "},{"$f":"IF('1. Leading well'!D14=\"\",\"\",'1. Leading well'!D14)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F14),\"No\",'1. Leading well'!F14)","v":"No"}]
[null,{"$f":"'1. Leading well'!B15","v":1.8},{"$f":"'1. Leading well'!C15","v":"Health and social care services undertake a process of co-production with people living with dementia when designing new services  "},{"$f":"IF('1. Leading well'!D15=\"\",\"\",'1. Leading well'!D15)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F15),\"No\",'1. Leading well'!F15)","v":"No"}]
[null,{"$f":"'1. Leading well'!B16","v":1.9},{"$f":"'1. Leading well'!C16","v":"Health and social care services engage in forecasting the projected dementia population and trends for the purposes of planning services in line with the needs of the population"},{"$f":"IF('1. Leading well'!D16=\"\",\"\",'1. Leading well'!D16)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F16),\"No\",'1. Leading well'!F16)","v":"No"}]
[null,{"$f":"'1. Leading well'!B17","v":1.1000000000000001},{"$f":"'1. Leading well'!C17","v":"Commissioned services are tailored to the needs of underserved groups and those from diverse communities"},{"$f":"IF('1. Leading well'!D17=\"\",\"\",'1. Leading well'!D17)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F17),\"No\",'1. Leading well'!F17)","v":"No"}]
[null,{"$f":"'1. Leading well'!B18","v":1.1100000000000001},{"$f":"'1. Leading well'!C18","v":"Commissioned services take into account the individual needs of those living alone with dementia"},{"$f":"IF('1. Leading well'!D18=\"\",\"\",'1. Leading well'!D18)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F18),\"No\",'1. Leading well'!F18)","v":"No"}]
[null,{"$f":"'1. Leading well'!B19","v":1.1200000000000001},{"$f":"'1. Leading well'!C19","v":"Commissioned services have improvement plans to address identified health inequality gaps  "},{"$f":"IF('1. Leading well'!D19=\"\",\"\",'1. Leading well'!D19)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F19),\"No\",'1. Leading well'!F19)","v":"No"}]
[null,{"$f":"'1. Leading well'!B20","v":1.1299999999999999},{"$f":"'1. Leading well'!C20","v":"Commissioned services undertake dementia-focused equality impact assessments to evaluate the effect of service changes on the local populations and communities"},{"$f":"IF('1. Leading well'!D20=\"\",\"\",'1. Leading well'!D20)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F20),\"No\",'1. Leading well'!F20)","v":"National Priority"}]
[null,{"$f":"'1. Leading well'!B22","v":1.1399999999999999},{"$f":"'1. Leading well'!C22","v":"Health, social care and relevant third sector organisations apply a tiered dementia training programme, which is monitored and reported"},{"$f":"IF('1. Leading well'!D22=\"\",\"\",'1. Leading well'!D22)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F22),\"No\",'1. Leading well'!F22)","v":"National Priority"}]
[null,{"$f":"'1. Leading well'!B23","v":1.1499999999999999},{"$f":"'1. Leading well'!C23","v":"Education and training for unpaid carers is delivered, monitored and tailored to their needs"},{"$f":"IF('1. Leading well'!D23=\"\",\"\",'1. Leading well'!D23)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F23),\"No\",'1. Leading well'!F23)","v":"National Priority"}]
[null,{"$f":"'1. Leading well'!B24","v":1.1599999999999999},{"$f":"'1. Leading well'!C24","v":"The community workforce who deliver palliative care and end of life care receive dedicated dementia training"},{"$f":"IF('1. Leading well'!D24=\"\",\"\",'1. Leading well'!D24)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F24),\"No\",'1. Leading well'!F24)","v":"No"}]
[null,{"$f":"'1. Leading well'!B25","v":1.17},{"$f":"'1. Leading well'!C25","v":"Carers support services receive training on the specific needs of those caring for people with a young-onset dementia diagnosis"},{"$f":"IF('1. Leading well'!D25=\"\",\"\",'1. Leading well'!D25)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F25),\"No\",'1. Leading well'!F25)","v":"No"}]
[null,{"$f":"'1. Leading well'!B27","v":1.18},{"$f":"'1. Leading well'!C27","v":"The ICB has a co-ordinated dementia strategy and improvement plan in place"},{"$f":"IF('1. Leading well'!D27=\"\",\"\",'1. Leading well'!D27)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F27),\"No\",'1. Leading well'!F27)","v":"National Priority"}]
[null,{"$f":"'1. Leading well'!B28","v":1.19},{"$f":"'1. Leading well'!C28","v":"The ICB has multi-agency governance in place to provide oversight and leadership  "},{"$f":"IF('1. Leading well'!D28=\"\",\"\",'1. Leading well'!D28)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F28),\"No\",'1. Leading well'!F28)","v":"No"}]
[null,{"$f":"'1. Leading well'!B29","v":1.2},{"$f":"'1. Leading well'!C29","v":"Dementia performance metrics are reviewed at ICB level and overseen by a co-ordinated, multi-agency group  "},{"$f":"IF('1. Leading well'!D29=\"\",\"\",'1. Leading well'!D29)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F29),\"No\",'1. Leading well'!F29)","v":"National Priority"}]
[null,{"$f":"'1. Leading well'!B30","v":1.21},{"$f":"'1. Leading well'!C30","v":"Dementia performance metrics include a focus on health inequality risk areas, such as the lack of dementia assessments in care homes"},{"$f":"IF('1. Leading well'!D30=\"\",\"\",'1. Leading well'!D30)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F30),\"No\",'1. Leading well'!F30)","v":"No"}]
[null,{"$f":"'1. Leading well'!B31","v":1.22},{"$f":"'1. Leading well'!C31","v":"The ICB annually reviews the prescription rates of anti-psychotic medication for the treatment of dementia "},{"$f":"IF('1. Leading well'!D31=\"\",\"\",'1. Leading well'!D31)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F31),\"No\",'1. Leading well'!F31)","v":"No"}]
[null,{"$f":"'1. Leading well'!B32","v":1.23},{"$f":"'1. Leading well'!C32","v":"Quality assurance checks are built into the commissioning of all care provision to monitor the delivery of high quality care "},{"$f":"IF('1. Leading well'!D32=\"\",\"\",'1. Leading well'!D32)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F32),\"No\",'1. Leading well'!F32)","v":"No"}]
[null,{"$f":"'1. Leading well'!B33","v":1.24},{"$f":"'1. Leading well'!C33","v":"Local authorities have a current Place-based Carers' Strategy in place with a specific section on dementia "},{"$f":"IF('1. Leading well'!D33=\"\",\"\",'1. Leading well'!D33)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F33),\"No\",'1. Leading well'!F33)","v":"No"}]
[null,{"$f":"'1. Leading well'!B34","v":1.25},{"$f":"'1. Leading well'!C34","v":"All providers participate in relevant national audits and results are used to drive improvements"},{"$f":"IF('1. Leading well'!D34=\"\",\"\",'1. Leading well'!D34)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F34),\"No\",'1. Leading well'!F34)","v":"No"}]
[null,{"$f":"'1. Leading well'!B35","v":1.26},{"$f":"'1. Leading well'!C35","v":"There are mechanisms in place across all health and social care providers for assessing whether dignity and respect are demonstrated in the delivery of care"},{"$f":"IF('1. Leading well'!D35=\"\",\"\",'1. Leading well'!D35)","v":""},{"$f":"IF(ISBLANK('1. Leading well'!F35),\"No\",'1. Leading well'!F35)","v":"No"}]
[null,"Pillar 2: Preventing Well"]
[null,{"$f":"'2. Preventing well'!B6","v":2.1},{"$f":"'2. Preventing well'!C6","v":"Healthy living messaging references dementia and provides guidance on healthy lifestyle choices"},{"$f":"IF('2. Preventing well'!D6=\"\",\"\",'2. Preventing well'!D6)","v":""},{"$f":"IF(ISBLANK('2. Preventing well'!F6),\"No\",'2. Preventing well'!F6)","v":"No"}]
[null,{"$f":"'2. Preventing well'!B7","v":2.2000000000000002},{"$f":"'2. Preventing well'!C7","v":"Healthy ageing messaging references that addressing hearing loss and increasing social activity can reduce the risk of loneliness and dementia"},{"$f":"IF('2. Preventing well'!D7=\"\",\"\",'2. Preventing well'!D7)","v":""},{"$f":"IF(ISBLANK('2. Preventing well'!F7),\"No\",'2. Preventing well'!F7)","v":"No"}]
[null,{"$f":"'2. Preventing well'!B8","v":2.2999999999999998},{"$f":"'2. Preventing well'!C8","v":"Discussions on risk factors for cardiovascular disease, and how they relate to dementia, are recorded for all NHS Health Checks.\nAdditional discussions around signs and symptoms of dementia are recorded in NHS Healthchecks for those aged 65 and above."},{"$f":"IF('2. Preventing well'!D8=\"\",\"\",'2. Preventing well'!D8)","v":""},{"$f":"IF(ISBLANK('2. Preventing well'!F8),\"No\",'2. Preventing well'!F8)","v":"No"}]
[null,{"$f":"'2. Preventing well'!B9","v":2.4},{"$f":"'2. Preventing well'!C9","v":"There is consistent messaging around modifiable factors in reducing the risk of developing dementia across wider clinical services"},{"$f":"IF('2. Preventing well'!D9=\"\",\"\",'2. Preventing well'!D9)","v":""},{"$f":"IF(ISBLANK('2. Preventing well'!F9),\"No\",'2. Preventing well'!F9)","v":"No"}]
[null,{"$f":"'2. Preventing well'!B10","v":2.5},{"$f":"'2. Preventing well'!C10","v":"Public Health initiatives around dementia have the effect of reducing stigma and offering hope, as well being realistic that dementia is a life limiting condition"},{"$f":"IF('2. Preventing well'!D10=\"\",\"\",'2. Preventing well'!D10)","v":""},{"$f":"IF(ISBLANK('2. Preventing well'!F10),\"No\",'2. Preventing well'!F10)","v":"No"}]
[null,{"$f":"'2. Preventing well'!B11","v":2.6},{"$f":"'2. Preventing well'!C11","v":"Dementia awareness events take place regularly within communities "},{"$f":"IF('2. Preventing well'!D11=\"\",\"\",'2. Preventing well'!D11)","v":""},{"$f":"IF(ISBLANK('2. Preventing well'!F11),\"No\",'2. Preventing well'!F11)","v":"No"}]
[null,{"$f":"'2. Preventing well'!B13","v":2.7},{"$f":"'2. Preventing well'!C13","v":"Dementia awareness is established in schools, colleges and universities in order to reach young people "},{"$f":"IF('2. Preventing well'!D13=\"\",\"\",'2. Preventing well'!D13)","v":""},{"$f":"IF(ISBLANK('2. Preventing well'!F13),\"No\",'2. Preventing well'!F13)","v":"No"}]
[null,{"$f":"'2. Preventing well'!B14","v":2.8},{"$f":"'2. Preventing well'!C14","v":"Community assets are utilised for the purposes of messaging of risks and encouraging the establishment of supportive environments for people living with dementia "},{"$f":"IF('2. Preventing well'!D14=\"\",\"\",'2. Preventing well'!D14)","v":""},{"$f":"IF(ISBLANK('2. Preventing well'!F14),\"No\",'2. Preventing well'!F14)","v":"No"}]
[null,{"$f":"'2. Preventing well'!B16","v":2.9},{"$f":"'2. Preventing well'!C16","v":"Strategies addressing the wider and social determinants of health reference their impact on dementia risk"},{"$f":"IF('2. Preventing well'!D16=\"\",\"\",'2. Preventing well'!D16)","v":""},{"$f":"IF(ISBLANK('2. Preventing well'!F16),\"No\",'2. Preventing well'!F16)","v":"National Priority"}]
[null,"Pillar 3: Diagnosing Well"]
[null,{"$f":"'3. Diagnosing well'!B6","v":3.1},{"$f":"'3. Diagnosing well'!C6","v":"There are plans in place to increase the number of people who access local dementia diagnostic services from culturally diverse and underserved communities"},{"$f":"IF('3. Diagnosing well'!D6=\"\",\"\",'3. Diagnosing well'!D6)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F6),\"No\",'3. Diagnosing well'!F6)","v":"No"}]
[null,{"$f":"'3. Diagnosing well'!B7","v":3.2},{"$f":"'3. Diagnosing well'!C7","v":"Dementia diagnostic provision is designed in a way that enables equal access for people suspected of all types of dementia, including young-onset dementia and those with learning disabilities"},{"$f":"IF('3. Diagnosing well'!D7=\"\",\"\",'3. Diagnosing well'!D7)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F7),\"No\",'3. Diagnosing well'!F7)","v":"No"}]
[null,{"$f":"'3. Diagnosing well'!B8","v":3.3},{"$f":"'3. Diagnosing well'!C8","v":"Referral pathways to diagnosis are reviewed annually to ensure people access and receive a diagnosis in an equitable way "},{"$f":"IF('3. Diagnosing well'!D8=\"\",\"\",'3. Diagnosing well'!D8)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F8),\"No\",'3. Diagnosing well'!F8)","v":"No"}]
[null,{"$f":"'3. Diagnosing well'!B10","v":3.4},{"$f":"'3. Diagnosing well'!C10","v":"People living with dementia are provided with a single named health or social care professional who is responsible for coordinating their care from assessment to end of life "},{"$f":"IF('3. Diagnosing well'!D10=\"\",\"\",'3. Diagnosing well'!D10)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F10),\"No\",'3. Diagnosing well'!F10)","v":"National Priority"}]
[null,{"$f":"'3. Diagnosing well'!B11","v":3.5},{"$f":"'3. Diagnosing well'!C11","v":"There are formalised arrangements that enable multidisciplinary team meetings between diagnostic service provider clinicians and other specialisms"},{"$f":"IF('3. Diagnosing well'!D11=\"\",\"\",'3. Diagnosing well'!D11)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F11),\"No\",'3. Diagnosing well'!F11)","v":"No"}]
[null,{"$f":"'3. Diagnosing well'!B12","v":3.6},{"$f":"'3. Diagnosing well'!C12","v":"Dementia diagnostic service providers signpost to carer support groups available within the community "},{"$f":"IF('3. Diagnosing well'!D12=\"\",\"\",'3. Diagnosing well'!D12)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F12),\"No\",'3. Diagnosing well'!F12)","v":"No"}]
[null,{"$f":"'3. Diagnosing well'!B14","v":3.7},{"$f":"'3. Diagnosing well'!C14","v":"People with suspected dementia have an initial assessment within 6 weeks of referral and, where possible, receive a diagnosis and start treatment"},{"$f":"IF('3. Diagnosing well'!D14=\"\",\"\",'3. Diagnosing well'!D14)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F14),\"No\",'3. Diagnosing well'!F14)","v":"National Priority"}]
[null,{"$f":"'3. Diagnosing well'!B15","v":3.8},{"$f":"'3. Diagnosing well'!C15","v":"Dementia diagnostic service providers have a process in place to monitor the time it takes from referral to assessment, diagnosis, and treatment which informs continuous improvement"},{"$f":"IF('3. Diagnosing well'!D15=\"\",\"\",'3. Diagnosing well'!D15)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F15),\"No\",'3. Diagnosing well'!F15)","v":"No"}]
[null,{"$f":"'3. Diagnosing well'!B16","v":3.9},{"$f":"'3. Diagnosing well'!C16","v":"Provisions are made for assessing cognitive impairment and providing treatment in urgent or crisis situations, with follow-up diagnostic pathways available"},{"$f":"IF('3. Diagnosing well'!D16=\"\",\"\",'3. Diagnosing well'!D16)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F16),\"No\",'3. Diagnosing well'!F16)","v":"No"}]
[null,{"$f":"'3. Diagnosing well'!B17","v":3.1},{"$f":"'3. Diagnosing well'!C17","v":"There is advice available for general practice to undertake accurate and appropriate referrals to diagnostic services"},{"$f":"IF('3. Diagnosing well'!D17=\"\",\"\",'3. Diagnosing well'!D17)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F17),\"No\",'3. Diagnosing well'!F17)","v":"No"}]
[null,{"$f":"'3. Diagnosing well'!B19","v":3.11},{"$f":"'3. Diagnosing well'!C19","v":"Consent is sought to involve family or carers in the diagnostic process and decisions around care and treatment "},{"$f":"IF('3. Diagnosing well'!D19=\"\",\"\",'3. Diagnosing well'!D19)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F19),\"No\",'3. Diagnosing well'!F19)","v":"No"}]
[null,{"$f":"'3. Diagnosing well'!B20","v":3.12},{"$f":"'3. Diagnosing well'!C20","v":"There is a mechanism in place to enable holistic personalised care and support plans to be created and updated by all agencies involved in the care of the person with dementia "},{"$f":"IF('3. Diagnosing well'!D20=\"\",\"\",'3. Diagnosing well'!D20)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F20),\"No\",'3. Diagnosing well'!F20)","v":"National Priority"}]
[null,{"$f":"'3. Diagnosing well'!B21","v":3.13},{"$f":"'3. Diagnosing well'!C21","v":"People with a dementia diagnosis have had their care and support plan reviewed in the preceding 12 months"},{"$f":"IF('3. Diagnosing well'!D21=\"\",\"\",'3. Diagnosing well'!D21)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F21),\"No\",'3. Diagnosing well'!F21)","v":"No"}]
[null,{"$f":"'3. Diagnosing well'!B22","v":3.14},{"$f":"'3. Diagnosing well'!C22","v":"Primary care providers and commissioners monitor compliance with personalised care and support planning, in line with best practice"},{"$f":"IF('3. Diagnosing well'!D22=\"\",\"\",'3. Diagnosing well'!D22)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F22),\"No\",'3. Diagnosing well'!F22)","v":"No"}]
[null,{"$f":"'3. Diagnosing well'!B23","v":3.15},{"$f":"'3. Diagnosing well'!C23","v":"People living with dementia and their carers receive clear and documented communication on what to expect in the disease's progression and how to manage this in their personal circumstances "},{"$f":"IF('3. Diagnosing well'!D23=\"\",\"\",'3. Diagnosing well'!D23)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F23),\"No\",'3. Diagnosing well'!F23)","v":"No"}]
[null,{"$f":"'3. Diagnosing well'!B24","v":3.16},{"$f":"'3. Diagnosing well'!C24","v":"Patients newly diagnosed with dementia are encouraged to plan ahead, including considerations of the Health and Finance LPAs"},{"$f":"IF('3. Diagnosing well'!D24=\"\",\"\",'3. Diagnosing well'!D24)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F24),\"No\",'3. Diagnosing well'!F24)","v":"No"}]
[null,{"$f":"'3. Diagnosing well'!B25","v":3.17},{"$f":"'3. Diagnosing well'!C25","v":"NHS Talking Therapies is promoted as a potential avenue for treatment following a dementia diagnosis"},{"$f":"IF('3. Diagnosing well'!D25=\"\",\"\",'3. Diagnosing well'!D25)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F25),\"No\",'3. Diagnosing well'!F25)","v":"No"}]
[null,{"$f":"'3. Diagnosing well'!B26","v":3.18},{"$f":"'3. Diagnosing well'!C26","v":"There are clear onward referral pathways from local diagnostic service providers to relevant partner agencies to provide support for people living with dementia and their carers"},{"$f":"IF('3. Diagnosing well'!D26=\"\",\"\",'3. Diagnosing well'!D26)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F26),\"No\",'3. Diagnosing well'!F26)","v":"No"}]
[null,{"$f":"'3. Diagnosing well'!B27","v":3.19},{"$f":"'3. Diagnosing well'!C27","v":"Pharmacological interventions are delivered in line with the NICE dementia guideline"},{"$f":"IF('3. Diagnosing well'!D27=\"\",\"\",'3. Diagnosing well'!D27)","v":""},{"$f":"IF(ISBLANK('3. Diagnosing well'!F27),\"No\",'3. Diagnosing well'!F27)","v":"National Priority"}]
[null,"Pillar 4a: Supporting Well in the Community"]
[null,{"$f":"'4a. Supporting well'!B7","v":"4.1a"},{"$f":"'4a. Supporting well'!C7","v":"People living with dementia should have equal access to intermediate care (rehabilitation, reablement and recovery) provision from a person with relevant training"},{"$f":"IF('4a. Supporting well'!D7=\"\",\"\",'4a. Supporting well'!D7)","v":""},{"$f":"IF(ISBLANK('4a. Supporting well'!F7),\"No\",'4a. Supporting well'!F7)","v":"No"}]
[null,{"$f":"'4a. Supporting well'!B8","v":"4.2a"},{"$f":"'4a. Supporting well'!C8","v":"Non-pharmacological interventions are delivered in line with the NICE dementia guideline"},{"$f":"IF('4a. Supporting well'!D8=\"\",\"\",'4a. Supporting well'!D8)","v":""},{"$f":"IF(ISBLANK('4a. Supporting well'!F8),\"No\",'4a. Supporting well'!F8)","v":"National Priority"}]
[null,{"$f":"'4a. Supporting well'!B9","v":"4.3a"},{"$f":"'4a. Supporting well'!C9","v":"People with dementia have a structured assessment before starting non-pharmacological or pharmacological treatment for distress"},{"$f":"IF('4a. Supporting well'!D9=\"\",\"\",'4a. Supporting well'!D9)","v":""},{"$f":"IF(ISBLANK('4a. Supporting well'!F9),\"No\",'4a. Supporting well'!F9)","v":"No"}]
[null,{"$f":"'4a. Supporting well'!B10","v":"4.4a"},{"$f":"'4a. Supporting well'!C10","v":"People with dementia have discussed and documented an advance decision about future emergency care"},{"$f":"IF('4a. Supporting well'!D10=\"\",\"\",'4a. Supporting well'!D10)","v":""},{"$f":"IF(ISBLANK('4a. Supporting well'!F10),\"No\",'4a. Supporting well'!F10)","v":"No"}]
[null,{"$f":"'4a. Supporting well'!B11","v":"4.5a"},{"$f":"'4a. Supporting well'!C11","v":"Structured medication reviews are undertaken post diagnosis at regular intervals by Primary Care"},{"$f":"IF('4a. Supporting well'!D11=\"\",\"\",'4a. Supporting well'!D11)","v":""},{"$f":"IF(ISBLANK('4a. Supporting well'!F11),\"No\",'4a. Supporting well'!F11)","v":"No"}]
[null,{"$f":"'4a. Supporting well'!B12","v":"4.6a"},{"$f":"'4a. Supporting well'!C12","v":"Observational tools are used for assessing pain in people living with dementia"},{"$f":"IF('4a. Supporting well'!D12=\"\",\"\",'4a. Supporting well'!D12)","v":""},{"$f":"IF(ISBLANK('4a. Supporting well'!F12),\"No\",'4a. Supporting well'!F12)","v":"No"}]
[null,{"$f":"'4a. Supporting well'!B14","v":"4.7a"},{"$f":"'4a. Supporting well'!C14","v":"Care providers support people living with dementia by making dementia-friendly, person-centred activities available and supporting engagement  "},{"$f":"IF('4a. Supporting well'!D14=\"\",\"\",'4a. Supporting well'!D14)","v":""},{"$f":"IF(ISBLANK('4a. Supporting well'!F14),\"No\",'4a. Supporting well'!F14)","v":"No"}]
[null,{"$f":"'4a. Supporting well'!B15","v":"4.8a"},{"$f":"'4a. Supporting well'!C15","v":"There is a standardised approach to care provider package assessments which incorporates input from the person living with dementia, their carers and the wider MDT"},{"$f":"IF('4a. Supporting well'!D15=\"\",\"\",'4a. Supporting well'!D15)","v":""},{"$f":"IF(ISBLANK('4a. Supporting well'!F15),\"No\",'4a. Supporting well'!F15)","v":"No"}]
[null,{"$f":"'4a. Supporting well'!B16","v":"4.9a"},{"$f":"'4a. Supporting well'!C16","v":"Care providers regularly review home-based packages of care following initial set up"},{"$f":"IF('4a. Supporting well'!D16=\"\",\"\",'4a. Supporting well'!D16)","v":""},{"$f":"IF(ISBLANK('4a. Supporting well'!F16),\"No\",'4a. Supporting well'!F16)","v":"No"}]
[null,{"$f":"'4a. Supporting well'!B18","v":"4.10a"},{"$f":"'4a. Supporting well'!C18","v":"Written and verbal communications are accessible in multiple languages and for those who are visually or hearing impaired "},{"$f":"IF('4a. Supporting well'!D18=\"\",\"\",'4a. Supporting well'!D18)","v":""},{"$f":"IF(ISBLANK('4a. Supporting well'!F18),\"No\",'4a. Supporting well'!F18)","v":"No"}]
[null,{"$f":"'4a. Supporting well'!B19","v":"4.11a"},{"$f":"'4a. Supporting well'!C19","v":"Communication aids are used to support communication with people living with dementia"},{"$f":"IF('4a. Supporting well'!D19=\"\",\"\",'4a. Supporting well'!D19)","v":""},{"$f":"IF(ISBLANK('4a. Supporting well'!F19),\"No\",'4a. Supporting well'!F19)","v":"No"}]
[null,"Pillar 4b: Supporting Well in Hospital"]
[null,{"$f":"'4b. Supporting well'!B7","v":"4.1b"},{"$f":"'4b. Supporting well'!C7","v":"Adaptations are in place to accommodate the needs of people with dementia while in the Emergency Department"},{"$f":"IF('4b. Supporting well'!D7=\"\",\"\",'4b. Supporting well'!D7)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F7),\"No\",'4b. Supporting well'!F7)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B9","v":"4.2b"},{"$f":"'4b. Supporting well'!C9","v":"Clinical teams have access to a dementia specialist for advice, patient review, and to facilitate good communication with people living with dementia and their carers"},{"$f":"IF('4b. Supporting well'!D9=\"\",\"\",'4b. Supporting well'!D9)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F9),\"No\",'4b. Supporting well'!F9)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B10","v":"4.3b"},{"$f":"'4b. Supporting well'!C10","v":"On admission, the person living with dementia, and their families and carers, are informed of the named clinician responsible for their care and how to access them during the hospital stay "},{"$f":"IF('4b. Supporting well'!D10=\"\",\"\",'4b. Supporting well'!D10)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F10),\"No\",'4b. Supporting well'!F10)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B11","v":"4.4b"},{"$f":"'4b. Supporting well'!C11","v":"Community care co-ordinators and professionals involved in care at home are contacted to make them aware of admission into hospital"},{"$f":"IF('4b. Supporting well'!D11=\"\",\"\",'4b. Supporting well'!D11)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F11),\"No\",'4b. Supporting well'!F11)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B13","v":"4.5b"},{"$f":"'4b. Supporting well'!C13","v":"Delirium screening is undertaken using a structured screening tool, such as 4AT"},{"$f":"IF('4b. Supporting well'!D13=\"\",\"\",'4b. Supporting well'!D13)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F13),\"No\",'4b. Supporting well'!F13)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B14","v":"4.6b"},{"$f":"'4b. Supporting well'!C14","v":"Carers are welcomed and supported during a hospital admission, in line with John's Campaign"},{"$f":"IF('4b. Supporting well'!D14=\"\",\"\",'4b. Supporting well'!D14)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F14),\"No\",'4b. Supporting well'!F14)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B15","v":"4.7b"},{"$f":"'4b. Supporting well'!C15","v":"Inpatient ward environments are designed in ways that meet the needs of people living with dementia"},{"$f":"IF('4b. Supporting well'!D15=\"\",\"\",'4b. Supporting well'!D15)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F15),\"No\",'4b. Supporting well'!F15)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B16","v":"4.8b"},{"$f":"'4b. Supporting well'!C16","v":"Medication reviews are undertaken during the inpatient stay"},{"$f":"IF('4b. Supporting well'!D16=\"\",\"\",'4b. Supporting well'!D16)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F16),\"No\",'4b. Supporting well'!F16)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B17","v":"4.9b"},{"$f":"'4b. Supporting well'!C17","v":"Risks associated with frailty and dementia are monitored during an inpatient stay, such as malnutrition, dehydration and falls"},{"$f":"IF('4b. Supporting well'!D17=\"\",\"\",'4b. Supporting well'!D17)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F17),\"No\",'4b. Supporting well'!F17)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B18","v":"4.10b"},{"$f":"'4b. Supporting well'!C18","v":"During an acute admission to hospital, people experiencing dementia have the opportunity to review and revise their advance care plan "},{"$f":"IF('4b. Supporting well'!D18=\"\",\"\",'4b. Supporting well'!D18)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F18),\"No\",'4b. Supporting well'!F18)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B19","v":"4.11b"},{"$f":"'4b. Supporting well'!C19","v":"There are person-centred, dementia inclusive activities available and an activities coordinator actively engages with inpatients living with dementia "},{"$f":"IF('4b. Supporting well'!D19=\"\",\"\",'4b. Supporting well'!D19)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F19),\"No\",'4b. Supporting well'!F19)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B21","v":"4.12b"},{"$f":"'4b. Supporting well'!C21","v":"Written and verbal communications are accessible in multiple languages and for those who are visually or hearing impaired "},{"$f":"IF('4b. Supporting well'!D21=\"\",\"\",'4b. Supporting well'!D21)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F21),\"No\",'4b. Supporting well'!F21)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B22","v":"4.13b"},{"$f":"'4b. Supporting well'!C22","v":"Communication aids are used to support communication with people living with dementia"},{"$f":"IF('4b. Supporting well'!D22=\"\",\"\",'4b. Supporting well'!D22)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F22),\"No\",'4b. Supporting well'!F22)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B24","v":"4.14b"},{"$f":"'4b. Supporting well'!C24","v":"All hospital staff are trained in how to raise a safeguarding concern, with specific awareness on people living with dementia "},{"$f":"IF('4b. Supporting well'!D24=\"\",\"\",'4b. Supporting well'!D24)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F24),\"No\",'4b. Supporting well'!F24)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B25","v":"4.15b"},{"$f":"'4b. Supporting well'!C25","v":"A mental capacity assessment is undertaken and a Deprivation of Liberty Safeguards document and / or Mental Health Assessment is completed for all inpatients who lack mental capacity without clinical rationale"},{"$f":"IF('4b. Supporting well'!D25=\"\",\"\",'4b. Supporting well'!D25)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F25),\"No\",'4b. Supporting well'!F25)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B26","v":"4.16b"},{"$f":"'4b. Supporting well'!C26","v":"There is a procedure in place for Deprivation of Liberty to be completed out of hours "},{"$f":"IF('4b. Supporting well'!D26=\"\",\"\",'4b. Supporting well'!D26)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F26),\"No\",'4b. Supporting well'!F26)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B28","v":"4.17b"},{"$f":"'4b. Supporting well'!C28","v":"Discharge planning is started at the point of admission, or before elective procedures, with mechanisms available to involve the multi-disciplinary team, as required"},{"$f":"IF('4b. Supporting well'!D28=\"\",\"\",'4b. Supporting well'!D28)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F28),\"No\",'4b. Supporting well'!F28)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B29","v":"4.18b"},{"$f":"'4b. Supporting well'!C29","v":"Patients living with dementia, their carers and families are supported with relevant information on discharge, including as a minimum, a copy of the discharge summary, with details of medication and any future appointments"},{"$f":"IF('4b. Supporting well'!D29=\"\",\"\",'4b. Supporting well'!D29)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F29),\"No\",'4b. Supporting well'!F29)","v":"No"}]
[null,{"$f":"'4b. Supporting well'!B30","v":"4.19b"},{"$f":"'4b. Supporting well'!C30","v":"There are clear and standardised pathways for appropriate referrals from hospital to dementia diagnostic service providers"},{"$f":"IF('4b. Supporting well'!D30=\"\",\"\",'4b. Supporting well'!D30)","v":""},{"$f":"IF(ISBLANK('4b. Supporting well'!F30),\"No\",'4b. Supporting well'!F30)","v":"No"}]
[null,"Pillar 5: Living Well"]
[null,{"$f":"'5. Living well'!B6","v":5.0999999999999996},{"$f":"'5. Living well'!C6","v":"Local authorities have policies in place to ensure their neighbourhoods are safe and welcoming for people living with dementia"},{"$f":"IF('5. Living well'!D6=\"\",\"\",'5. Living well'!D6)","v":""},{"$f":"IF(ISBLANK('5. Living well'!F6),\"No\",'5. Living well'!F6)","v":"No"}]
[null,{"$f":"'5. Living well'!B7","v":5.2},{"$f":"'5. Living well'!C7","v":"Local authorities have plans and policies in place to improve the accessibility of the physical environment for people living with dementia "},{"$f":"IF('5. Living well'!D7=\"\",\"\",'5. Living well'!D7)","v":""},{"$f":"IF(ISBLANK('5. Living well'!F7),\"No\",'5. Living well'!F7)","v":"No"}]
[null,{"$f":"'5. Living well'!B8","v":5.3},{"$f":"'5. Living well'!C8","v":"Community events and activities that promote wellbeing are organised, and held regularly, in response to feedback from people living with dementia and their carers "},{"$f":"IF('5. Living well'!D8=\"\",\"\",'5. Living well'!D8)","v":""},{"$f":"IF(ISBLANK('5. Living well'!F8),\"No\",'5. Living well'!F8)","v":"No"}]
[null,{"$f":"'5. Living well'!B9","v":5.4},{"$f":"'5. Living well'!C9","v":"Community events and activities are accessible for people living with dementia and their carers"},{"$f":"IF('5. Living well'!D9=\"\",\"\",'5. Living well'!D9)","v":""},{"$f":"IF(ISBLANK('5. Living well'!F9),\"No\",'5. Living well'!F9)","v":"No"}]
[null,{"$f":"'5. Living well'!B11","v":5.5},{"$f":"'5. Living well'!C11","v":"A range of suitable urgent community-based services are commissioned, including crisis prevention, urgent, and intensive support services"},{"$f":"IF('5. Living well'!D11=\"\",\"\",'5. Living well'!D11)","v":""},{"$f":"IF(ISBLANK('5. Living well'!F11),\"No\",'5. Living well'!F11)","v":"National Priority"}]
[null,{"$f":"'5. Living well'!B12","v":5.6},{"$f":"'5. Living well'!C12","v":"Ambulance services have avenues for seeking advice when required and access to suitable alternative pathways to out of hospital services "},{"$f":"IF('5. Living well'!D12=\"\",\"\",'5. Living well'!D12)","v":""},{"$f":"IF(ISBLANK('5. Living well'!F12),\"No\",'5. Living well'!F12)","v":"No"}]
[null,{"$f":"'5. Living well'!B14","v":5.7},{"$f":"'5. Living well'!C14","v":"Advice is given to carers about their right to carer assessment, and accessibility to respite care, breaks, and support groups"},{"$f":"IF('5. Living well'!D14=\"\",\"\",'5. Living well'!D14)","v":""},{"$f":"IF(ISBLANK('5. Living well'!F14),\"No\",'5. Living well'!F14)","v":"National Priority"}]
[null,{"$f":"'5. Living well'!B15","v":5.8},{"$f":"'5. Living well'!C15","v":"Interventions for carers are evidence-based, appropriate, and tailored according to their age, ethnicity, religion, gender, and sexual orientation"},{"$f":"IF('5. Living well'!D15=\"\",\"\",'5. Living well'!D15)","v":""},{"$f":"IF(ISBLANK('5. Living well'!F15),\"No\",'5. Living well'!F15)","v":"No"}]
[null,"Pillar 6: Dying Well"]
[null,{"$f":"'6. Dying Well'!B6","v":6.1},{"$f":"'6. Dying Well'!C6","v":"Advance care plans are offered and recorded, in line with the person's wishes"},{"$f":"IF('6. Dying Well'!D6=\"\",\"\",'6. Dying Well'!D6)","v":""},{"$f":"IF(ISBLANK('6. Dying Well'!F6),\"No\",'6. Dying Well'!F6)","v":"No"}]
[null,{"$f":"'6. Dying Well'!B7","v":6.2},{"$f":"'6. Dying Well'!C7","v":"A systematic, proactive approach is used to identify people living with dementia who are also likely to be in the last 12 months of life"},{"$f":"IF('6. Dying Well'!D7=\"\",\"\",'6. Dying Well'!D7)","v":""},{"$f":"IF(ISBLANK('6. Dying Well'!F7),\"No\",'6. Dying Well'!F7)","v":"No"}]
[null,{"$f":"'6. Dying Well'!B9","v":6.3},{"$f":"'6. Dying Well'!C9","v":"People living with dementia who are also identified as likely to be in the last 12 months of life are added to the GP palliative care register"},{"$f":"IF('6. Dying Well'!D9=\"\",\"\",'6. Dying Well'!D9)","v":""},{"$f":"IF(ISBLANK('6. Dying Well'!F9),\"No\",'6. Dying Well'!F9)","v":"No"}]
[null,{"$f":"'6. Dying Well'!B10","v":6.4},{"$f":"'6. Dying Well'!C10","v":"People living with dementia are enabled to continue living at home, and to die there if that is their wish, through effective coordination and continuity of care delivery across services"},{"$f":"IF('6. Dying Well'!D10=\"\",\"\",'6. Dying Well'!D10)","v":""},{"$f":"IF(ISBLANK('6. Dying Well'!F10),\"No\",'6. Dying Well'!F10)","v":"No"}]
[null,{"$f":"'6. Dying Well'!B11","v":6.5},{"$f":"'6. Dying Well'!C11","v":"Integrated multidisciplinary approaches are taken to the delivery of palliative care and end of life care for people living with dementia"},{"$f":"IF('6. Dying Well'!D11=\"\",\"\",'6. Dying Well'!D11)","v":""},{"$f":"IF(ISBLANK('6. Dying Well'!F11),\"No\",'6. Dying Well'!F11)","v":"National Priority"}]
[null,{"$f":"'6. Dying Well'!B12","v":6.6},{"$f":"'6. Dying Well'!C12","v":"People living with dementia have equity of access to timely specialist palliative care, as required"},{"$f":"IF('6. Dying Well'!D12=\"\",\"\",'6. Dying Well'!D12)","v":""},{"$f":"IF(ISBLANK('6. Dying Well'!F12),\"No\",'6. Dying Well'!F12)","v":"No"}]
[null,{"$f":"'6. Dying Well'!B14","v":6.7},{"$f":"'6. Dying Well'!C14","v":"Health and care professionals have the knowledge, skills, and confidence to undertake effective advance care planning conversations "},{"$f":"IF('6. Dying Well'!D14=\"\",\"\",'6. Dying Well'!D14)","v":""},{"$f":"IF(ISBLANK('6. Dying Well'!F14),\"No\",'6. Dying Well'!F14)","v":"No"}]
[null,{"$f":"'6. Dying Well'!B15","v":6.8},{"$f":"'6. Dying Well'!C15","v":"Health and social care professionals have the knowledge, skills and confidence to provide high quality palliative care and end of life care to people living with dementia"},{"$f":"IF('6. Dying Well'!D15=\"\",\"\",'6. Dying Well'!D15)","v":""},{"$f":"IF(ISBLANK('6. Dying Well'!F15),\"No\",'6. Dying Well'!F15)","v":"No"}]