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Debra Llewellyn, Julia Wilkinson and Alison Watkins

Carmarthenshire County Council with industry partner, Delta Wellbeing Limited

This Bevan Exemplar project focuses on providing dementia care that takes the whole person’s needs into account, including physical, emotional, social and economic well-being.


Currently, there is a tendency for domiciliary care to focus on providing physical care rather than supporting a person’s emotional, social or economic well-being. People with dementia often enter social services at a time of crisis and it is vital that their care reflects their holistic needs.


The aim of the Fulfilled Lives model of care for people living with dementia is to provide holistic support that will enable people to live their life as their dementia progresses. The focus will be on the individual directing the support that they need to maximise their independence.

The intention of the model is to coordinate support around the individual’s network, working alongside the person with dementia and the community to help maintain their independence. The model aims to avoid unnecessary dependency on services and to ensure that people come in to the service at a time in their life when they are able to plan for their future and engage fully in managing their own health and well-being.

Next steps:

Embedding a preventative approach is essential to complement this model, including:

  • Development of dementia friendly communities and shopping areas.
  • Dementia awareness programmes – over 5000 dementia friends have been trained.
  • Maximise opportunities to use Technology Enabled Care.
  • Specific dementia element within the “CUSP model” – a third sector preventative community support project.


Expectations of the families of those with dementia was an issue at the start of the project, especially as the service was new, but the team us now able to clearly explain the service at the outset.

Identifying the appropriate assistive technology has also been an issue that the team has worked on, particularly using medication dispensers and getting them filled by local pharmacies. The team developed bespoke training to build staff knowledge, and worked with the lead community pharmacist to address pharmacists’ concerns regarding medication governance.

Did you know?

All staff confirmed that they enjoy the role of a key worker and felt that it was different to the role of a Home Carer. When asked to score out of 10 for job satisfaction, all key workers scored 10. When asked to score out of 10, how well the project is achieving what it set out to achieve, the average score was 9.

Reasons that staff felt the Key Worker role was different included: “more flexible”; “more rewarding”; “more structured and person centred”; “feeling part of a team”; “having direct contact with other professionals”.


For the pilot group of people with dementia (compared to a cohort receiving traditional domiciliary care):

  • The outcomes achieved with people with dementia have been very positive.
  • The amount of support required was gradually reduced or maintained, compared to the 60% escalation of care hours in the other cohort.
  • 80% of people with dementia remained living at home after 8 months.
  • Unscheduled care hospital stays were reduced by an average of 11.5 days over the year
  • There were no deaths in the pilot group, compared to 11 deaths in the similar cohort.

Next steps:

The plan is to commence rolling out the model of care in Ammanford and Llandeilo early in 2019, followed by Carmarthen later in the year. The team also wants to commission a formal evaluation of the project to share with regional partners.

“I know I am making a difference.”

Key Worker

“Staff are more independent and flexible in their approach.”


“Both Dad and the family are experiencing new experiences and more opportunities…. We are not only learning about the past we are building new memories.

Mum really enjoys going out with the Key Worker. She goes to Knit and Natter, and mostly natters!

My Grandad has a good relationship with the Key Worker and sometimes calls him by my father’s name, this reassures us that we know he likes him. I feel like I can breathe again, it has made a big difference for us.”