The development of integrated services for older people with complex needs and long term conditions, including dementia, is one of the key priorities of the Cardiff and Vale of Glamorgan Regional Partnership Board.


Our Vision is to improve the health and well-being of older people, no matter how complex their needs, so that they are supported to maintain their independence and live a fulfilling life. As set out in the Social Services and Well-being (Wales) Act 2014, we will achieve this by:

  • Improving care and support, ensuring people have more choice and control;
  • Improving outcomes and health and well-being;
  • Providing coordinated, person centred care and support;
  • Making more effective use of resources, skills and expertise.

In 2020-21 funding supported a number of critical areas

Signposting and Crisis Response

The Integrated Care Fund has continued to support Cardiff Council’s Independent Living Service and the Vale of Glamorgan Council’s Contact 1 Vale. Both services exemplify the benefits that a single point of access to an array of partner-provided services can have for local citizens.

  • Contact 1 Vale
    6,000 referrals assessed
  • 81% dealt with directly with 0% onward referral to social services.

View the impact of the Contact 1 Vale service

Cardiff Independent Living Service

  • 2,734 referrals were received
  • 83% of cases dealt with directly with no onward referral to social services
  • 256 home visits were undertaken

Click to read the wide range of activity on offer at the 50+ Active Body Healthy Mind Virtual Spring Festival March 2021English

Newssheet 50+ Active Body Healthy Mind Virtual Spring Festival March 2021 Welsh

Accelerated Cluster Model & Social Prescribing

One of our Transformation Fund projects has allowed a group of GP practices in the South West Cluster in Cardiff to develop new ways of working. The key developments for the cluster have been:

– to support people better on discharge from hospital,

– improving links to independent living services through a multi-disciplinary approach,

– and pioneering a new social prescribing platform.

Whilst delivery was hampered by COVID-19, work continued to improved outcomes for local citizens:

  • 4,740 patients contacted to offer support and signposting.
  • Community-based, multi-disciplinary teams discussed 231 individual patients.
  • GPs referred 277 patients through the social prescribing platform (alternative to traditional approaches) for assistance and support.

Intermediate Care

Both ICF and Transformation Funds support a range of intermediate care services that provide citizens with the care they require as close to their own home as possible.  Local citizens can be admitted from home (step up), or from one of the larger hospitals (step down).

Get Me Home

Hear how integrated support is delivered across projects funded by the ICF and Transformation Fund to get people home. Together, the projects work with an overarching aim of collaboration for improving the patient journey and providing integrated support to meet the needs of the individual.  Making their transition from clinical care, through rehabilitation to independent living.

The projects include:

A single point of contact within the hospital for discharge and community-based services, removing duplication and inconsistency, and improving co-ordination and information sharing.

The Pink Army – a team providing a single point of contact for Cardiff citizens and their families. 

Age Connect Discharge Liaison Officers for Vale citizens and their families.

Both teams use ‘What Matters’ conversations to trigger holistic, tailored support that meets the wellbeing needs of the individual, providing preventative interventions and supporting independent living.

Additional Community Resource Team support with funding for Physiotherapists, Occupational Therapists, Social Workers, Social Work Assistance, Third Sector Co-ordinators and domiciliary care support for step up and step-down care.

Get Me Home Plus – coordinated reablement and homecare support

The Get Me Home Plus care model pilot focuses on fast tracking more impaired patients who have been assessed as requiring level two or three support, to restart or establish a new package of care in order to return home. Centering recovery in the patient’s usual home surroundings reduces further deconditioning and the risk of hospital acquired infections

Although data collection was disrupted by COVID-19, quantitative metrics; qualitative feedback and case studies collected by the projects showed:

  • Patients supported with discharge from hospital and encouraged to remain independent. Hear how integrated support is delivered across service providers.
  • Reduced need for social care packages
  • Reduced length of stay
  • Improved communication between different services
  • Fast discharge from hospital and no delayed discharge
“…they supported me whilst I waited for a room in a care home where I now have what I need –  electric chair/bed.  And now I can maintain my independence.

Service user

… has been great providing to patients on the ward to support safe discharges. There is improved communication on the ward between health staff and social services in regards to waiting on information around package of care and communication to social workers.” Occupational Therapist

Accommodation Solutions

The ICF has continued to support 12 flats for the short-term use of local citizens to assist hospital discharge or prevent admission.

Whilst the team received a lower number of referrals than normal due to COVID-19, they were still able assist 142 people in their discharge from hospital at an estimated saving of £380,485.

A digital case study highlighting this project can be viewed here 

Dementia Care

Through support from the Welsh Government Integrated Care Fund, the RPB was able to support initiatives guided by the Cardiff and Vale Draft Dementia Strategy 2017-2027, that see health and social care services working together to support older people with dementia.

So that our actions could make a clear difference at a local level, we engaged with representatives from Cardiff and Vale University Health Board, Cardiff Council, Vale Council, and the Alzheimer’s Society, along with a person living with dementia and a person with experience of caring for a person with dementia.

Dementia Friendly Communities

The Dementia Friendly team at Constantinou Hair & Beauty, Cardiff

Dementia Friendly Communities’ is a programme developed by the Alzheimer’s Society which facilitates the creation of dementia friendly communities across the UK. The programme aims to engage organisations, local businesses, front-line staff and members of the public to share the responsibility for ensuring people with dementia feel understood, valued and able to contribute to their communities.

We have been blown away by the support and education from Ingrid *💗 We are proud to now be a Dementia Friend and will continue to learn and develop our understanding of Dementia. If you know any local businesses who would benefit from this training, we can highly recommend it.  Helen Rouse – Director of O. Constantinou & Sons (Hair and Beauty Salon) in Cardiff pledged to become a dementia friendly business in July 2020

In collaboration with Marie Curie volunteers, the RPB has facilitated dementia friends training across Cardiff and the Vale of Glamorgan with a view to becoming a Dementia Friendly Region. There are now over 7,000 dementia friends.  In early 2020 a Dementia Friendly business pilot was launched.  Independent hair and beauty salon O Constantinou & Sons in Cardiff were the first to successfully pledge to become a Dementia Friendly business.

*Ingrid Patterson – Dementia Friendly Communities Coordinator for Cardiff and Vale of Glamorgan

Subsequently, nine organisations pledged to become Dementia Friendly during 2020 – 2021.

Dementia friendly communities newssheet Feb 21 Welsh

Dementia friendly communities newssheet Feb 21

Dementia Friendly communities newssheet April 2021

Dementia Learning and Development Team

It is recognised that patients living with cognitive impairment prefer coordinated and streamlined care being delivered ‘closer to home’.  It is also important that patients living with dementia have seamless transitions between services and that they may benefit from access to a named contact who can help to navigate their ‘journey’ living with dementia to ensure that the right person is involved at the right time and in the right place.

Partnership working to Support those living with dementia

Thanks to funding provided by Welsh Government a collaboration led Dr Cherry Shute, Locum Consultant Geriatrician within the Memory Team at Llandough Hospital and Dr Keziah Maizey a GP with a specialist interest in memory based at Llandaff North Medical Centre to develop and deliver a unique and pioneering system to improve the experiences of those living with dementia and their loved ones.

Funding was used for a Positive Approaches to Care (PAC) certified, Dementia Care training team to train colleagues in primary care who review patients in their local area to achieve the competencies outlined within the Good Work Framework for Wales.  This has resulted in improved rates of dementia diagnosis in Cardiff and the Vale. but more than that, has provided a safer environment, closer to home that many vulnerable patients will benefit from when being diagnosed with a life-changing condition.  The feedback from patients reviewed in the GP clinics has been resoundingly positive.

In addition, funding has also enabled the Dementia Learning and Development Team in Cardiff to develop the role of the memory link worker.  These individuals have come from various backgrounds in health and social care.  They work within different localities within Cardiff and the Vale as per GP practice, helping them to develop close working relationships with GP’s, local services and allied health care professionals.  The memory link workers have been integral to our operations as a memory team over the past few years in acting as a link or connector for patients to help them navigate the healthcare system and ensure patients are referred to the right person at the right time to address their needs.

How the funding was used

  • Training eight General Practitioners to develop a specialist interest in memory
  • Building capacity in local clinics to review circa 700 patients per annum
  • Recruiting eight memory link workers, to work closely between primary and secondary care services making an average 5400 contacts with patients a year.  Reducing burden on already stretched primary care services and the risk of crisis admissions
  • 110 staff received skills training
  • GP comment,  “I constantly receive positive verbal feedback from patients and their carers about the benefits of having memory clinics in GP practices.  They find it less intimidating, more accessible for those with disabilities”.

    Funding occupational, speech and language therapists and dieticians with cognition  interest within the Community Resource Team in Cardiff and the Vale Community Resource Service.

 ‘One of the best training sessions I have attended, it helped me think about what the person living with dementia is experiencing’.

In parallel, the dementia care mapping (DCM) activity of the team provides an evidenced-based approach to collecting information on the lived experience of dementia. The information is then shared with others to encourage critical reflection on practice, and to develop and improve person centred care across the workforce.

To find out more about the impact of the Partnership’s work to support older people, please click on the sections below.