DementiaRoadmap Wales

Promoting living well with dementia across Wales

Care planning

A person with dementia will need an increasing amount of support as the condition progresses. Their local authority has a duty to carry out a Community Care assessment when requested, which will assess the person's needs and decide which services could be arranged to help meet them. If the department assesses a person as being in need of certain services, it has a duty to provide the services that fall within the council’s eligibility criteria. To arrange an assessment, call the local authority Adult Social Care Services.

A person using specialist health and social care teams such as a Community Mental Health Team will be supported by a care plan with details about what treatment or care will be provided by whom.

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Resources

  • National Dementia Vision for WalesSeptember 25 2011The National Dementia Vision for Wales sets the Welsh governmnet's vision to strengthen communities, creating a key resource for people affected by dementia at local and national level. The objective being that over time, building on local improvements from the grass roots up, a network of local dementia supportive communities will create a national dementia supportive community.
  • Fulfilled Lives, Supportive Communities: A Strategy for Social Services in Wales over the next decadeFebruary 21 2007This strategy describes how modern accessible and responsive social services, delivered flexibly, consistently and sustainably across organisational boundaries will contribute to a better Wales and to improving the lives of its citizens.
  • Accessible Information StandardJuly 28 2015The Accessible Information Standard tells organisations how they should ensure that disabled patients receive information in formats that they can understand and they receive appropriate support to help them to communicate.
  • Dementia core skills education and training frameworkOctober 29 2015This framework published by Skills for Health, Health Education England and Skills for Care sets out the essential skills and knowledge necessary for all staff involved in dementia care.
  • Prevalence of dementia in population groups by protected characteristics: a systematic review of the literatureOctober 2 2015This literature review published by Public Health England examines evidence on how the prevalence of dementia varies with different characteristics, such as ethnicity, gender and religion.
  • Dementia stakeholder groups – action plansJune 29 2011These plans outline actions for improvement across four key priority areas: improving service provision, early diagnosis, access to information and training.
  • Spirituality and ageing: implications for the care and support of older peopleJanuary 22 2013This briefing paper published the Institute for Research and Innovation in Social Services explores why our ageing population requires person-centred care and developmental support in order to maximise its chances of ageing well.
  • Tailored resource for carers and care providers on supporting people to live well with dementiaSeptember 16 2015This resource published by the National Institute for Health and Care Excellence (NICE) highlights the key messages from 10 quality statements which form the quality standard for supporting people to live well with dementia and shows what they mean for carers and care providers.
  • Duty of Candour: Information for all providersMarch 15 2015This document published by the Care Quality Commission sets out how meeting the Duty of Candour regulation will be central to both registration and inspection for NHS bodies and all other care providers regulated by the CQC.
  • Dementia and People with Intellectual Disabilities: Guidance on their Assessment, Diagnosis, Interventions and SupportApril 29 2015This guidance published by the British Psychological Society aims to promote effective and timely assessment, diagnosis, interventions and support to people with intellectual disabilities who develop dementia.
  • Prime Minister’s challenge on dementia 2020February 21 2015The Prime Minister recently launched the government’s five year vision for the future of dementia care, support and research, which follows on from the existing Prime Minister’s Challenge on Dementia, launched in March 2012.
  • NICE Clinical guideline CG42 Dementia: supporting people with dementia and their carers in health and social careMarch 1 2011This guideline, published by the National Institute for Health and Clinical Excellence (NICE), makes specific recommendations on Alzheimer's disease, dementia with Lewy bodies (DLB), fronto temporal dementia, vascular dementia and mixed dementias, as well as recommendations that apply to all types of dementia.
  • Unlocking Diagnosis: The key to improving the lives of people with dementiaJuly 4 2012This report published by the All-Party Parliamentary Group on Dementia (APPG) explores the barriers to dementia diagnosis in the UK. It makes recommendations to improve diagnosis rates and provide better post diagnosis support for people with dementia.
  • Five Year Forward ViewOctober 23 2014The Five Year Forward View published by NHS England sets out why the NHS needs to change and various models of care which could be provided in the future to deliver transformed care for patients.
  • Prepared to care – Challenging the dementia skills gapJune 4 2009This report published by the All-Party Parliamentary Group on Dementia (APPG) explores the scale of the challenge in training the caring professions in dementia, and how it may be met.
  • The £20 Billion Question – An inquiry into improving lives through cost-effective dementia servicesJuly 4 2011This report published by the All-Party Parliamentary Group on Dementia (APPG) explores the the evidence for cost effective models of dementia care. It makes recommendations to focus on early intervention and prevention to reduce early entry to residential care and reduce unnecessary hospital admissions.
  • A Misspent Opportunity? Inquiry into the funding of the National Dementia StrategyMarch 18 2010This report published by the All-Party Parliamentary Group on Dementia (APPG) examines initial progress made by Primary Care Trusts in England towards implementing the National Dementia Strategy for England.
  • QS30: Supporting people to live well with dementiaApril 3 2013This quality standard, published by the National Institute for Health and Care Excellence (NICE), covers the care and support of people with dementia.
  • Dementia: A state of the nation report on dementia care and support in EnglandNovember 29 2013This report, published by the Department of Health, sets out what is known about dementia care, support and research. It highlights where improvements are being made and where improvements are needed.
  • The dementia guideFebruary 22 2014This guide produced by the Alzheimer's Society is for anyone who has recently been told they have dementia.
  • Building dementia-friendly communities: A priority for everyoneSeptember 3 2013This report, published by the Alzheimer's Society, explores evidence from people with dementia about their experiences of living in their community and the ten key things they would like to see in a dementia-friendly community.
  • Better care for older peopleJuly 11 2014This online resource published by the General Medical Council aims to help doctors challenge the stereotypes associated with older people and tackle the most common concerns older people have about their care.
  • NHS Continuing Healthcare e-learning toolMay 8 2013This e-learning tool developed by NHS England and the Association of Directors of Adult Social Services will support all practitioners to improve assessment and decision making around NHS Continuing Healthcare.
  • The Care Bill: factsheetsJanuary 10 2014These factsheets will help practitioners to better support patients and carers to get the care and support they need, following the changes introduced by the Care Bill, published in 2013.
  • CMG48: Support for commissioning of dementia careApril 3 2013This guidance produced by the National Institute for Health and Clinical Excellence (NICE) summarises the key commissioning issues and the resource impact that will arise from implementing improvements in the quality of care for people with dementia, in line with the statements and measures that comprise the NICE quality standards for dementia.
  • Collaborative Care and Support Planning: an introductionJanuary 19 2015This animation, commissioned by the Royal College of General Practitioners, sets out the collaborative care and support planning process in a short, easy to understand way.
  • Initial review following diagnosisMay 7 2014This guidance outlines the steps that a practitioner should consider during an initial review with a patient that has received a formal diagnosis of dementia.
  • Dementia: ethical issuesJanuary 25 2010This report published by the Nuffield Council on Bioethics presents an ethical framework to help practitioners who face dilemmas in connection with the everyday care of someone with dementia.
  • State of Care 2013/14October 16 2014This report published by the Care Quality Commission (CQC) reveals wide variation in the quality and safety of care for conditions such as dementia in England.
  • Ten tips for communicating with a person with dementiaSeptember 8 2012These top tips produced by the Family Caregiver Alliance will help practitioners and those caring for a person with dementia to improve communication skills and ability to handle the difficult behaviour.
  • Template action plan to improve care for people with dementia in the communityJuly 28 2011This is a template action plan for use by local authorities and commissioning consortia working together under the auspices of Health and Well-being Boards to improve care for those people with dementia who live in their own homes or in some other residential setting.
  • Dewis CymruApril 27 2018Dewis Cymru is a website that provides information and advice about well-being. In addition to health information, Dewis Cymru provides information about people and services in your area that can help you with the things that matter to you.
  • Advance Care PlanningMarch 28 2019If you were to lose the capacity to make decisions about your life today, what are the important things you would like those caring for you to know about you and what you would want to happen? One way of making people aware of your wishes is by a process that is called advance care planning.
  • Preparing for a Social Services Care Needs AssessmentTips for people with Dementia on preparing for a social services care needs assessment can be found on the Alzheimers UK website, link below.  http://www.alzheimers.org.uk/get-support/legal-financial/dementia-care-needs-assessment  
  • Social Services Support for DementiaEven if you feel you don't need support now, it's a good idea to know what's available and plan ahead. The adult social services department of your local council can help with your personal care and day-to-day activities. The first step is to arrange a needs assessment.
  • NHS Continuing Healthcare and NHS-funded Nursing CareNHS Continuing Healthcare  If you have complex health and care needs, the NHS may cover the cost of all your care at home or in a care home, including the services you receive from the local council. This is called continuing healthcare and is funded ...
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