North East Lincolnshire Memory Service – Navigo – HC – #MHAwards18

The Memory Service is the overarching umbrella for mini teams of the core Memory Service which undertakes assessments from referral. The assessments are CPA or non-CPA, through diagnosis, treatment, interventions via post diagnostic support and complex case management through to discharge and sign-posting to other relevant agencies and support. The Memory Service is a multidisciplinary team of Doctors, Mental Health Nurses, Social Workers, Support Workers, Occupational Therapists, OT Technicians, Psychologists, Assistant Psychologist, Admiral Nurses and Admin. We have some staff trained as Advanced Dementia Practitioners (ADPs) who are able to diagnose dementia. We have Nurse Prescribers. We have a Support Worker currently undertaking Nurse Associate training.

Highly Commended in Specialist Services Category - #MHAwards18


  • From start: No
  • During process: Yes
  • In evaluation: No


  • Peer: Yes
  • Academic: No
  • PP Collaborative: Yes

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Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.

The Memory Service is the overarching umbrella for mini teams of the core Memory Service which undertakes assessments from referral. The assessments are CPA or non-CPA, through diagnosis, treatment, interventions via post diagnostic support and complex case management through to discharge and sign-posting to other relevant agencies and support. The Memory Service is a multidisciplinary team of Doctors, Mental Health Nurses, Social Workers, Support Workers, Occupational Therapists, OT Technicians, Psychologists, Assistant Psychologist, Admiral Nurses and Admin. We have some staff trained as Advanced Dementia Practitioners (ADPs) who are able to diagnose dementia. We have Nurse Prescribers. We have a Support Worker currently undertaking Nurse Associate training. The core Memory Team can refer to our team of OTs, Admiral Nurses and Psychology. We also have a dedicated Care Home Liaison team who manage those in generic care homes and more complex service-users in enhanced care home placements. There is a part time Social Worker who manages the Huntington’s Disease caseload. There is also a Functional team co-located with the Memory Service with some cases joint worked.


In May 2017 there was an organisational consultation with all staff and a review of community teams, including Older People’s Services and the Memory Service, looking at how the whole staff group, at all levels, wished to develop services. From this a number of work-streams were set up to meet bi-weekly with all staff involved in at least one work-stream, to input their ideas to look at re-shaping many areas of the service. They included numerous areas of development including CPD sessions; there is dedicated time every three months for staff to meet as a service group with staff themselves identifying specific topics and speakers.

This ensures that all teams can contribute; previously the smaller teams organised training for their teams such as CST and different types of dementia. All older peoples services are located on one site. Clinics are held within the Primary Care centres within North East Lincolnshire. There is ongoing work to create additional clinic space within Primary Care for additional clinics. All clinicians have Dashboards on their Desktops therefore can access data in regard to their workloads which is updated daily. Managers also have a Dashboard regarding Memory Service data which is also updated daily. This includes data in regard to those who have been referred to Memory Service, time of referral to assessment and those accessing psychosocial interventions. The data is updated daily. All clinicians have laptops to enable them to work off-site. We have revised the pathways for Learning Disability, MCI and Younger People with Dementia are being finalised. We now have a clinician overseeing research projects including the NHS National Institute for Health Research. Information is given to all service-users and carers regarding ‘Join Dementia Research’, should they want the information, as part of the post-diagnostic follow up. We have a tablet whereby service-users and carers can register their interest immediately online. There is a research programme which the service is involved with, Care Givers Pro with NHS Humber Foundation Trust in partnership with Hull University.

Due to difficulties in recruiting Psychiatrists, we have been creative and established the Advance Dementia Practitioner (ADP) role. We have three qualified and one in the process of undertaking the relevant course whereby they are able to diagnose more straightforward dementias, allowing time for the Consultants to manage the complex presentations, dementias and reviews. We have introduced Direct Booking whereby the Clinician can arrange an OPA at the first / initial assessment directly with the OPA admin staff which is thus convenient for the service-user and for the clinician to be present.


There is a further successful complementary therapy service within the organisation, which provides beauty and holistic therapies and offers pamper and taster sessions for example during carers week. There are a number of changes in the staffing structure at present with new staff either having recently completed their induction or about to start with the team. One of our Consultants has retired at the end of February; we have a Locum for six months due to uses of recruitment. NAViGO had a CQC inspection in December 2017. NAViGO was rated as Good in our overall CQC well-led inspection with special recognition for care and compassion with Outstanding rating for caring. NAViGO is also the Lead for Dementia in the Accountable Care Partnership. We are working with other agencies who can provide specialist services like end of life and supporting them with training so the right people for the right part of a person’s journey are involved.


What makes your service stand out from others? Please provide an example of this.


We have just completed the fourth cycle of Memory Service Accreditation with the Royal College of Psychiatrists Memory Services National Accreditation Programme (MSNAP). In the first cycle we were one of the few Memory Services to be accredited as Excellent. We have continued to be accredited in the following cycles. The feedback from our recent Peer Review was outstanding. Comments were made about their wish to replicate aspects of our memory service in all memory services. One example of this is the NELLES group which is run weekly. NELLES is led by our Admiral Nurses and staff from our OT team and supported by the Alzheimer’s Society who work together to offer support to people with dementia and their family and friends. NELLES is an opportunity for carers to receive education and advice on caring for people with dementia and share their experiences with others. It is an opportunity for people with dementia to socialise and support one another in a friendly environment.



How do you ensure an effective, safe, compassionate and sustainable workforce?

We have a robust team of various professionals which include Nurses, Consultant Psychiatrist, Occupational Therapist, Psychologist, Team Manager, Administrators, Speech and Language Therapist, Dietician, Physiotherapist, Social Worker, Geriatrician, Neurologist and Admiral Nurses. When we have any vacancies we have used bank staff and staff have been offered additional hours which some have readily accepted.

How do you work with the wider system?

We are proud that finally after two years of discussions with the commissioners and GPs, there was agreement in mid-2017 that GPs have now agreed for our service users to be discharged back to their care once they are established and settled on memory medication after three months. There is agreement that should the situation change, they can fast-track the service user back to the Memory Service. We work closely with the Alzheimer’s Society and advise those we discharge that they can also contact the Alzheimer’s Society for a wide range of support, groups and advice which they provide. We do not commission social care packages but work closely with Adult Social Care and frequently undertaken joint working with service users and carers. We have a wide range of other services that we can refer to such as the fire brigade for safety checks, benefits agency for financial advice, Friendship at Home who provide low level support for service users.


Do you use co-production approaches?

We have a robust group of volunteers across NAViGO; many of whom engage and assist with groups run for service-users and carers within the Memory Service. We have ‘Your Voice’ which are meetings twice monthly for service users, carers and staff to attend and hear about the organisation; guest speakers and how service users and carers as community members can become involved. We have had carers involved in delivering training; although we do not have any currently we encourage others to become involved.


Do you share your work with others?

We attend local events such as Dementia Action Alliance week; carer’s week. We have showcased Memory Service at the Memory Service’s conference with table top presentations.


What outcome measures are collected, how do you use them and how do they demonstrate improvement?

PREMS are used and data from them recorded on clinicians Dashboards. Also feedback circulated by the Quality team. We have many positive comments from service-users and carers. Service-users and carers also met with the Peer Review team for our re-accreditation.


Has your service been evaluated (by peer or academic review)?

As noted we are an accredited Memory Service.



How will you ensure that your service continues to deliver good mental health care?

We have excellent links with our commissioners and meet on a regular basis to discuss any areas of concern and have, across the organisation, secured additional funding to enhance our services.


What aspects of your service would you share with people who want to learn from you?

On 22nd May 2018 we were visited by the National Mental Health Director NHSE, Claire Murdoch, and a number of her colleagues. The purpose of the visit was to see first-hand all the services across NAViGO including Memory Service. Their feedback was how impressed they were by our values, the positivity and the pride of being part of NAViGO.


How many people do you see?

The current case load of the Memory Service is 760. The total number of referrals accepted each year is on average 750. We have a number of groups such as NELLES, CST, Memory Management and MCI that either run weekly or on a rolling programme. The numbers can range from 6 to 14 depending on the group.


How do people access the service?

The Memory Service takes referrals agreed by the service-users GP via our Single Point of Access. SPA directs the referrals to the team daily. Within the Memory Service we operate a duty system whereby all the qualified staff across the mini teams take a day on duty; fielding calls for their colleagues who are not in the office e.g., on leave, non-working day or to take general queries perhaps from GPs, Social care or other agencies.


How long do people wait to start receiving care?

The Single Point of Access forwards the referrals daily; allocation is three times weekly. Upon allocation the care coordinator contacts the service user within 48 hours and agrees to visit within ten working days for the initial assessment.


How do you ensure you provide timely access?

Any referrals received by Single Point of Access that are deemed urgent will be discussed between Memory Service and the Crisis Home Treatment Team on the same day to agree who should take the referral in the first instance.


What is your service doing to identify mental health inequalities?

We have a robust Performance team who collect data. They contribute to the Public Health Joint Strategic Needs Assessment Reports which profiles the local population and identifies any needs. The Performance team liaise with Public Health within North East Lincolnshire Council.

What inequalities have you identified regarding access to, and receipt and experience of, mental health care?

We have recently updated our pathway for learning disabilities and dementia. In the Memory Service we have link workers allocated to GP practices to enhance our links with primary care and to address these needs.

What is your service doing to address and advance equality?

All staff members have received training in the Mental Capacity Act which promotes and ensures service users human rights are adhered to for those who lack capacity to make decisions for themselves. The service works with service-users and carers in regard to advance planning such as Lasting Powers of Attorneys. We have Best Interest Assessors within Memory Service to further promote service users rights. All staff work in accordance with the Care Act.


How do you identify the needs of a person using the service ?

The assessment process takes account of the service users’ holistic needs and when required they may be referred to Psychology, Adult Social Care, Dietician, Speech and Language, Occupational Therapy and Physiotherapy.


How do you meet the needs of people using the service and how could you improve on this?

The assessment covers the holistic needs of the service-users and carers. It enables us to address any areas of concern as well as memory; we can advise and signpost to the relevant agencies. We have staff trained to take ECGs with a number of machines in the team and bloods. This enables tests to be done timely and any issues identified without delay. We have direct access to the CT department in the local hospital so service-users can take the form and do not have to wait days or weeks for an appointment.  We have robust support available within the team in regard to Occupational Therapy, dedicated Care Home Liaison team, Admiral Nurses and Functional team. We have a revised pathway with GPs to transfer cases back to their care. Although we have link workers within the team with Primary care we aim to improve the links and closer working relationships with Primary care We have someone dedicated to research within the team which is an area we are hoping to be more proactive in. All memory medication is in accordance with NICE guidelines.


What support do you offer families and carers? (where family/carers are not the service users)

We have a robust Admiral Nurse team with four Admiral Nurses all dedicated to supporting the families and carers of the service users. Memory Service in regard to the care coordinators and support workers also ensure they have taken account of carer’s needs and signpost for relevant carer’s assessments.


Further information

Memory Service is proud that we do not have a waiting list. Referrals are allocated, assessed and have a diagnosis on the whole within 8 to 12 weeks which is recognised as good practice as noted by our recent Memory Services review. We have a robust range of Psychosocial Interventions to offer service-users and carers which are group based and on a one to one basis. Training staff to be Advance Dementia Practitioners has been positive and enables us to have more clinics and therefore diagnose sooner. The Dashboards are a proactive way of managing caseloads and prompts to staff to prevent people falling through the net.


Population details

Brief description of population

North East Lincolnshire is a small unitary authority covering an area of 192km2 with a population of around 159,000. The majority of the resident population (around 94.2%) live in the urban towns of Grimsby and Cleethorpes with the remainder living in the smaller town of Immingham, or in surrounding rural villages. On the northern border, the Humber estuary has been designated as a Site of Special Scientific Interest and to the south, the Lincolnshire Wolds are recognised as an Area of Outstanding Natural Beauty. Cleethorpes gained four national Seaside Awards in 2015. North East Lincolnshire has a distinctive economy, built on expertise in manufacturing, engineering, ports and logistics, and food processing. The local area has some significant advantages stemming from its location, labour force, and transport infrastructure that position it for growth in renewables, chemicals, advanced manufacturing and the food and drink sector. Taken together, Grimsby and Immingham constitute the UK’s largest port by tonnage shipped. Whilst the general direction of travel for the locality is around improving the environment and perception of the area, North East Lincolnshire does have pockets of high deprivation, ranking high on the IMDO (Index of Multiple Deprivation) which measures the following 7 deprivation indicators:- • Income • Barriers to housing and services • Employment • Living Environment • Health/Disability • Crime • Education/Training An example, East and West Marsh, two Wards within the North East Lincolnshire Council area, now rank in the top 1% deprived sub-areas nationally. As a result of the deprivation there are long standing health inequalities with those in the more deprived areas dying on average 8 – 10 years before those in the most affluent. According to the National Office of Statistics, around 18.46% of the population have some sort of emotional disorder. Other key points to note:- • The boundary of North East Lincolnshire is comprised of 106 Lower Super Output Areas (LSOAs); these LSOAs which contain a minimum population of 1,000 and a mean average of 1,500 are distributed amongst the fifteen electoral wards. • Overall, North East Lincolnshire is ranked as the 31st most deprived local authority in England, out of 326. (Increased from 46th in the ID 2010). • 32,567 residents, which approximately 20% of the population are classed as income deprived with 25% of LSOAs being in the 10% most deprived for income nationally. • 15,140 residents are classed as employment deprived. • 20.1% of the working age (16 to 64) population of North East Lincolnshire have a known disability. • 95.4% of the resident population of NEL are White British. • The January 2015 School Census shows 23,541 children on roll, 2981 (12.5%) of school pupils were identified as having Special education needs. • Presently 28.5% (8,500) local children are thought to live below the poverty line.

Size of population and localities covered:

Population c159,000 – NAViGO covers the area of North East Lincolnshire

Commissioner and providers

Commissioned by (e.g. name of local authority, CCG, NHS England): *

North East Lincolnshire Clinical Commissioning Group (NELCCG) and NHS England (Rharian Fields and Liaison & Diversion Teams)

Provided by (e.g. name of NHS trust) or your organisation: *

NAViGO CIC – NAViGO is a not for profit social enterprise formed in 2011 under the Right to Request Agenda. The whole of Mental Health Services in North East Lincolnshire transferred out of the NHS yet is still the preferred provider to the NHS delivering both statutory and a range of innovative additional services in North East Lincolnshire. Becoming a social enterprise has allowed the organisation the autonomy to develop innovative projects. Any surplus made by working smarter is re-invested to improve services for local people.

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