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Community Matron Specialist Dementia Care Service

Who do we see?

People who have a Luton based GP and who are living in the community and have a diagnosis of dementia or who live in a care home and have Mild Cognitive Impairment (MCI)

Referral Route

Referrals are accepted from:

  • GPs
  • Memory Assessment Service (MAS)
  • Dementia Nurse Specialist at the Luton & Dunstable Hospital
  • Consultants at the Luton & Dunstable Hospital
  • Community Nurses
  • Social Services
  • Other Healthcare professionals

We are (currently) unable to accept self-referrals 

Hours of Work: 08.00 – 17.00hrs

The service is available Monday to Friday

There is no cover at weekends or bank holidays or when the nurse is on leave

Out of Hours the service is supported by the Integrated Adult Community Nursing Team Referral Management Service (RMS)

Telephone messages will be responded to within three working days subject to any leave

What are the objectives of the service?

 Provide comprehensive and holistic nursing, physical, psychological and social assessments

Support people living with dementia, their families and their carers

Identify carers needs

Advise and support in the management of dementia including mood, behavioural and psychological symptoms of dementia (BPSD

Undertake medication reviews: Anti-Dementia; Antipsychotic (neuroleptics); Antidepressants; Anxiolytics and Hypnotics

Promote person-centred care

Coordinate care between services

Care planning including hospital admission avoidance and advance care planning

Who are we? 

The service is provided by a Community Matron (physical health) – Specialist in Dementia Care NOT an Admiral Nurse

What can we provide?

  • Home visits for first contacts, brief interventions and reviews
  • Healthy lifestyle and health promotion
  • Telephone advice and signposting
  • Multi-agency referrals as appropriate
  • Person-centred (Hospital Admission Avoidance) Care Planning 
  • Advanced Care Planning including: preferences, decisions, advance directives/ statements etc.
  • Education of professionals involved in caring for people living with dementia and their family members or carers ¹
  • A single named professional who is responsible for coordinating care for people living with dementia 

Referral Criteria

  • People over 18 years of age who are registered with a Luton GP
  • People with a diagnosis of dementia living in the community 
  • People with cognitive impairment & no formal diagnosis of dementia living in Residential Care Homes
  • People with cognitive impairment & no formal diagnosis of dementia and under the care of the district nursing team

Signposting for Patients Who Do Not Meet Referral Criteria

  • People living in the community, their family members or carers who are concerned that a patient may be showing the signs of dementia but are, as yet, undiagnosed should be referred to their GP for dementia screening (collateral story from patient/ NoK/ carers, a blood test, urine dipstick & MSU if/ as indicated to exclude a reversible condition and a referral made to the (ELFT) Older People’s Community Mental Health Team Memory Assessment Service ( for a formal assessment and diagnosis

Luton Referral Management Service (RMS) contact details:

Phone: 0333 405 3000




Dementia Service

A bit of background about the service and how it fits in with the Specialist Palliative Care work?

People living with dementia (PLWD) experience palliative care needs as their dementia progresses and will require both palliative and end of life care

  •  Who runs the service ?
  • What does the service include?

A period of Intensive Case Management including:

  • Holistic nursing assessment including: communication; cognitive function; behaviour/ mood; level of function with Activities of Daily Living (ADLs): eating & drinking; toileting & continence; transferring/ moving/ walking; nutrition, hydration and weight management
  • Identification of carers needs
  1. Coordinated care & support between services
  2. Brief Interventions
  3. Advance Care & Support Planning
  • Person centred care
  • Hospital Admission Avoidance Care Planning with a ‘personalised element’
  • Personal Care & Support Planning including 'anticipatory' and 'personalised' elements

Anything else specific that you focus on?

  • Post diagnostic support for PLWD their families and carers
  • Planning for future care
  • Palliative & End of Life Care

Team members

  • Community Matron – Specialist in Dementia Care

Hours and days of availability

  • Monday to Friday 08.00 – 18.00hrs

Where is the service based?

  • The Poynt, Unit 2 – 3, Poynters Road, Luton, Bedfordshire, LU4 0LA

Contact details for the team

How to refer

Useful links and other organisations.

Alzheimer's Society Luton

Who we can help: people affected by dementia
Contact for referral: 01582 470 910 or

Support offered: telephone support and advice and guidance

Dementia advisers:  for information, support and advice. People living with dementia, or relatives, can speak to a trained dementia adviser who can learn more about your situation and give tailored information, advice and support.

Call Alzheimer’s Society Dementia Connect support line on 0333 150 3456:

The choice of when somebody should move into residential care can be very difficult. We have some advice on our website here which you may find helpful to read:…

We also have advice on why somebody with dementia may walk about and how you can help keep them safe:…

Feeling bad about having to stand your ground? You may also find this page on guilt helpful - and how to manage those feelings while caring for somebody:…

If you’re affected by Dementia and live in Luton you’re not alone. Our specialist services will help you:

  • get tailored information and advice from our experienced staff
  • keep your independence and improve your wellbeing
  • feel confident and supported
  • Get details of local groups and services

Contact the Luton team on 01582 470910 or email

Dementia Talking Point is Alzheimer’s Society’s online community for people with dementia, their family, friends and carers. It's a safe place to ask questions, share your experiences and get advice and support.

Visit Dementia Talking Point

SamaritansCall 116 123 or

Age UKCall 0800 169 2081

MindCall 0300 123 3393, text 86463


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"Seen very quickly. The nurse was very understanding, approachable and empathetic"  - Luton community paediatrics