Living Well in North Yorkshire

Find out how small improvements to a person's life or circumstances can improve their health, wellbeing and independence.

Living Well

As part of its wider prevention programme, North Yorkshire County Council has invested in a new Living Well team. The Living Well Coordinators will work with individuals (and their carers) who are on the cusp of becoming regular users of health and social care services by helping them access their local community and supporting them find their own solutions to their health and wellbeing goals. The role will help to reduce loneliness and isolation and help to prevent or resolve issues for people before they become a crisis.

As well as working with many teams within the council (such as public health and Stronger Communities), the living well team will also be working in partnership with NHS clinical commissioning groups, district councils and voluntary, community and social enterprise organisations (VCSE).

What do they do

Living Well in North Yorkshire aims to improve the health; wellbeing and independence of adults and in doing so reduce their use of formal support services, including emergency admissions to hospital. The core principles of the service are:

  • To provide free, time limited, targeted, support for appropriate people, not a default for all.
  • To promote independence and facilitate self-help
  • To work with individuals, not do for
  • To facilitate self-assessments and make referrals where appropriate.
  • To complement existing services, not to replicate voluntary services already in existence
  • To provide practical advice, information and support

Living Well Coordinators will spend time with individuals on a one-to-one basis to

  • Identify what is important to them, what potential networks of support they have and what their priorities are. They will work with individuals to achieve the outcomes that are important to them.
  • Help them make simple changes to their lifestyle and their home environment. This may, for example, include providing basic advice to help people be more active, improve their mobility and therefore increase their independence and reduce the risk of falling, 
  • Identify barriers and challenges to maintaining or improving their wellbeing and independence, and help to remove those barriers. For example, finding ways for a person to attend a local community group

As well as supporting people to maximise their own health, wellbeing and independence, Living Well Coordinators have excellent knowledge of local services and initiatives and where necessary they will support people to access those services.

This might range from access to home adaptations, such as a grab rail to prevent someone having a fall in their own home, support to access a local friendship club to stop someone feeling isolated, to providing advice on healthy living and sign posting to lifestyle services.

In addition to working with individuals, Living Well Coordinators will be extra eyes and ears in the community. They will provide feedback on the quality and availability of low level support in the community to health and care commissioners. 

They will also support the work of the stronger communities team to identify gaps, needs and community assets, providing information for the community directory. They will be visible in their local area; developing networks and links with other important services, such as community support officers, GPs, pharmacies, and community leaders.

Who can help

Living Well can support adults who are currently not eligible for on-going social care support and who are:

  • Individuals who are lonely and / or socially isolated
  • Individuals who have had a recent loss of a support network; including bereavement
  • Individuals who have had a loss of confidence due to a recent change / event
  • Individuals requiring face to face information, advice and guidance

This may be older people or people with physical, learning disabilities, sensory impairment or mental health needs.

Stories of people who are Living Well

There are as many stories as there are people who receive support and the strength of the team can be seen in the individual stories and positive outcomes that are being achieved by the Living Well Coordinators.

Here you can read and hear some inspirational stories about the life changing impact of the work they do.

Phyllis is a 67 year old woman who lives on her own. She contacted the council's customer service centre explaining that she needed some help. She has been unable to work for a number of years due to ill health. She suffered two heart attacks and as a result had to have numerous operations and has been left feeling very breathless. This has resulted in her becoming more and more isolated in her own home lacking the confidence to go out. She has no family nearby and her friends do not live locally. She had quite a lot of support from her neighbours but she didn't like to rely on them too much. She struggles to maintain her home and it gets her down.

What does she want to achieve?

Phyllis identified her financial situation as something she wanted to sort out and something that was causing her some distress. She also identified lots of other goals such as increasing exercise, improving her social life, being able to keep a clean and tidy home, doing small DIY jobs, finding a different means of transport, going back to the hair salon, gaining confidence with going out, and regaining her independence.

How did living well support Phyllis?

The living well agreement was used to ask her about her current situation and what she wanted to achieve. Identifying what strengths she had and support networks in place also enabled us to focus on the positives in her life and to build on them.

Phyllis agreed to be referred to the income maximisation team which helped her to gain attendance allowance and a reduction in her council tax bill. This meant she had more money to spend on social activities and jobs around the house.

Phyllis said that she had got to a stage where she had been in the four walls of her house for so long, not feeling that she could go out, that she became more and more demotivated. The living well coordinator provided support around motivation, helping to prioritise her goals. Visiting each week gave her the motivation to get the jobs done. Another area of support was to build her confidence to be able to connect with the local community, for example taking her to the local chair exercise group in the village hall which resulted in meeting people who offered her regular lifts to the class.

What was the outcome?

Phyllis achieved all her goals and many more! She has become a member of the U3A and joined several groups.

She has joined in with the local visiting scheme social activities She has regained confidence at leaving the house and has even decided to try driving again. She has bought a more economical car with the help from a friend and has also had help to sell her old one.

She has felt more motivated to get things done and feels happier that she is socialising with people and being able to talk to people about current affairs.

Phyllis said "Before living well I found that the less I did, the less I wanted to do. Now I feel motivated to do more and I am really enjoying meeting new people and learning new things".

Mr Jones had been diagnosed with dementia and was finding it difficult to come to terms with this. Mr Jones is unable to drive anymore and has had to submit his driving licence to the DVLA. He misses driving to popular areas in the countryside and going for a walk on his own or bird watching.

Mr Jones now has a bus pass and will take a bus journey, however, sometimes he is unable to understand the bus timetable and will just wait at the bus stop until one turns up.

Mrs Jones worries about Mr Jones when he goes out alone which means she never gets a break from her caring role; she gets very distressed when he doesn't come back at an agreed time.

Mrs Jones is happy to take on the driving, but Mr Jones has become a bit of a 'backseat driver' and this is discouraging Mrs Jones to drive sometimes.

Living well team involvement commenced when Mr and Mrs Jones contacted the council's customer service centre.

What do Mr and Mrs Jones want to achieve?

Meeting Mr and Mrs Jones and talking about what was important to them, it became apparent that Mr Jones would appreciate some support in finding out about opportunities to go for a walk and to be able to continue his interest of bird watching.

Mrs Jones would appreciate the opportunity to do something on her own without having that feeling of uncertainty that her husband is potentially unsafe so would like him to be with others if possible.

How did living well support them?

The living well coordinator introduced Mr Jones to the health walks run by Hambleton Strollers. Initially she accompanied Mr Jones on a couple of walks as he finds it difficult initially to engage with strangers and finds that if too many people are talking at once he is unable to follow the conversation. He was introduced to the group gradually and encouraged to get to know a few people. He got into a conversation about going bird watching and was told of the local nature reserve.

Mr Jones now thoroughly enjoys the walks and Mrs Jones has downloaded the dates and times of them for future reference. Mrs Jones said that she could take him to the start of the walk and pick him up, knowing that he was safe and not walking on his own. This would allow her to do something on her own without having that feeling of uncertainty that her husband was potentially unsafe.

What was the outcome?

Mr Jones is enjoying going out walking in a safe environment and making new friends and contacts in the community leading to potential new leisure opportunities. He is now aware of bird watching opportunities in the area and will make a decision whether to go to the local nature reserve.

Mr Jones said "I now feel able to join new walks and find it easier to speak to new people. I will just tell them I have a poor memory and that it's hard for me to join in conversations if too many people are talking".

Mrs Jones said "I am much happier now that I am not worrying about my husband going walking on his own and maybe getting lost and I can also get to spend some quality time on my own".

Mark is a young man in his twenties with autism who lives on his own in a studio bed sit. His parents, who have always been a constant support to him, have recently moved out of the area and his mother is worried that her son could be socially isolated.

What does Mark want to achieve?

There were a combination of issues facing Mark that he wanted support to tackle. On a practical level he wanted support to renew his bus pass and some support with his finances so that he could carry on with his activities.

He sometimes felt low in mood and socially isolated. He attended two activities in a nearby town that were long standing, but ideally he wanted something locally or he would like to move closer to his current hobbies. He was also keen to volunteer or work. Having tried many work trials without success, he was worried that his autistic tendencies were acting as a barrier. 

Mark also had some concerns about his physical and mental health; a leg injury affected his ability to walk and he was worried about his weight. 

How did living well support Mark?

Living well supported Mark to make the changes that he wanted to make, introducing him to activities near to his own home and gradually helping him to increase his confidence to make decisions on his own.

The coordinator helped him to register on North Yorkshire Home Choice so that he could search properties independently. Mark was introduced to the supported employment service which has since led to him receiving the support he needs to get a full time job. He was particularly interested in volunteering in the library to use his IT skills. Living well helped him to search and apply online and also to visit the library. After some training he now provides IT support and also helps out with other library activities.

Living well helped Mark to improve his physical and mental health by connecting him to the local weight management service, which led him to using the leisure centre and losing weight with Slimming World. He is now a regular attender at a local weekly social group and has reconnected with someone he had known at school.

What was the outcome?

Mark now feels far more confident and happy to live in the area and not move to another area as his social life has increased. He feels he has purpose in his volunteering and has been supported to get a job with a local company and he is taking some courses.

He can now use his bus pass to visit his parents and follow his interests. He will continue using the gym and might even start swimming again.

“It has been so lovely to have someone come and see me on my territory as I do not always feel comfortable with people. Since I have been working with you I am so much happier living here and my parents feel much better about having moved. I didn’t even know the things you have shown me existed”.

Albert is 78 years old and lives with his wife. Since his stroke last year he struggles with movement down the right side of his body and grasping with his hand. He has lost a lot of confidence in everyday pastimes that he once enjoyed such as painting, woodwork and card making. He does not enjoy groups and feels very passionate about having his independence to do things for himself. He has quite a lot of support from his wife but he doesn't like to rely on her too much. He was feeling very vulnerable and low and reported feeling "useless" now he can't make the things he once did. The referral came from the locality team following a discussion of what living well can do to support Albert.

What does he want to achieve?

Albert made it very clear that he wanted to find a volunteer who can help him with his woodwork and provide encouragement, knowledge and company, not to do the woodwork for him. He struggles to use his lathe both due to his grasp but also because his knowledge of the machine had faded.

The living well agreement was used to ask him about his current situation and what he wanted to achieve. The use of questions such as 'what's important to you?' and 'describe what a good day means to you' allowed the living well coordinator to find out more about Albert and how to support him. Identifying his strengths and support networks helped to focus on the positives in his life and to build on them.

His family is important to him with six children and three grandchildren who come for tea every week. Albert often sits in a separate room and does not engage unless anyone comes through to see him. After discussing this, Albert slowly gained the confidence to speak with his children about how he feels.

How did living well support Albert?

Some support was based around motivation and confidence building. The living well coordinator and Albert discussed how he was feeling and researched local voluntary groups together. Albert enjoyed taking the lead over his situation as it was control he felt he hadn't had for a long time. This increased his confidence and motivation to make changes.

Albert's request for a volunteer was so specific that the contact with local voluntary agencies was not successful and different approaches were taken by a) ringing the local Craven College Joinery section to ask if anyone would be interested in giving up some free time to come and aid Albert and b) creating an advert to place in a local DIY shop to attempt to find an appropriate volunteer.

What was the outcome?

Albert achieved his goal of finding a volunteer from the college that was able to support him with his woodwork. The volunteer was very creative and also played musical instruments, which he lent to Albert. Albert's confidence, self-worth and happiness grew as he dusted off his lathe and enjoyed time in his shed once again.

Albert said "I felt useless and less of a person because I couldn't do my woodwork anymore. Now I feel so much more confident with the support of my volunteer and able to do more for myself. Living well listened to what I wanted, and understood that I didn't want someone to take over".

Edna lives alone and feels isolated in her home after the loss of a loved one, and with her children having their own lives. She has lost some of her mobility and become increasingly dependent on others for help. She wanted social contact but had lost the confidence she needed to make the first move.

How did living well support Edna?

Living well supported Edna to arrange a transfer to a bungalow which was in a much better location for her to be able to get out and about. Once she had received support to build her confidence, she was able to be more active, walk to local facilities and take part in local social groups. With this new found confidence she was also able to get online and arrange to visit a cherished friend.

What was the outcome?

In  this recording Edna talks movingly about the way that living well took the time to get to know what was important to her and helped her to get her life back (mp3 / 2 MB).

Edna says "I now know that there really is life after 80".

Doreen is 84 years old and lives alone. Her only daughter lives far away. She has recently been diagnosed with dementia and the friends that she used to care for have passed away. She feels very lonely.

How did living well support Doreen?

Living well supported Doreen to build her own confidence; they introduced her to social groups and arranged a volunteer to visit regularly.

What was the outcome?

In  this recording Doreen talks about the ways that living well has helped her to build her confidence and her social connections (mp3 / 1 MB).

Doreen says "Living well has really helped me and I now have something to look forward to".

Frequently asked questions

The Living Well team is accepting referrals from adult social care when a person does not have a need for ongoing care and support.

If you need social care support and want to remain in your own home, there are many different options available, depending on your individual needs.

At present there isn't a definitive list of 'things' that the Living Well co-ordinator will do with a person.

It is a personalised service and it will vary as to what the individual wants to achieve. Living Well co-ordinators spend time with individuals on a one-to-one basis to identify what is important to them, what potential networks of support they have and what their priorities are. There is some support that the Living Well co-ordinator will not provide, such as personal care, befriending or domestic tasks such as shopping or cleaning.

Some of the types of support that have been provided so far include:

  • Support to build self-confidence;
  • Support with practical advice / skills - any advice provided that covers practical elements of their life or gaining / improving practical skills;
  • Advice on healthy living and sign posting to lifestyle services such as stop smoking or exercise;
  • Help to get online either in the home or using a universal / community service e.g. library or cyber café;
  • Help to become a volunteer or to access the community; and
  • Helping a person to be connected to, linked with or signposted to a voluntary agency for support or involvement for a specific support e.g. befriending, shopping, transport, advocacy etc.

Initially, when a worker from outside the council contacts our customer service centre, they will be referred to the Living Well team if the person could meet the requirements for the service.

If you are a worker from one of the Living Well partner organisations you can also contact the Living Well team to talk to one of the managers or co-ordinators.

You can contact the customer service centre here.

Living Well is working with a range of groups and external agencies, including health professionals. For professionals wanting to make referrals please refer to the information packs which provide information about the Living Well service and include a referral guide and contact details.

The Living Well team is currently accepting referrals from individuals who are referred through our customer service centre.

If a person contacts the customer service centre, one of the specialist social care advisors will listen to them and ask for more details about their situation to find out whether it is appropriate for Living Well or whether a different response is needed.

If a person is looking for support with daily living there is more information about social care support here.

You can contact the customer service centre here.

The Living Well team is currently accepting referrals from individuals who are referred through the customer service centre. If you contact us on behalf of someone else, one of the advisors will listen to you and ask for more details about the person, including whether they know that you are contacting the council for them.

Where possible, the advisor will call the person directly to gain their direct consent and will also speak to them to make sure it is appropriate for Living Well or whether a different response is needed.

You can contact the customer service centre here.

If you are not sure you can contact the customer service centre and talk it through with one of the specialist advisors.

If you are a worker from one of the Living Well partner organisations you can also contact the Living Well team to talk to one of the managers or co-ordinators.

You can contact the customer service centre here.

The support provided by the Living Well co-ordinators is free. However, if an individual decides to take part in a community activity then there may be a charge for that.

Although the Living Well co-ordinator will be able to signpost to the voluntary sector on some occasions which people may want, this will not be the default position.

The aim of the team is to promote sustainable independence and build on a person's own personal and community strengths.

This may include signposting to other organisations, including the voluntary sector when that is what people want. If a person is interested in a voluntary or community service, the Living Well co-ordinator will help them to access the service using the organisation's own referral process. Living Well does not make referrals on behalf of the person they are working with.

Living Well teams have developed a very good local knowledge in their area and this knowledge will help to identify people who could benefit from the service.

The team is also working with a selection of organisations to develop arrangements for working together.

The aim of Living Well is to encourage and support sustainable independence. If a person appears to need repeated episodes of Living Well, consideration will be given as to whether the person needs more long-term or different support.

Living Well is a form of targeted support and will not work for everyone.

Health and adult services is the lead county council directorate for Living Well.

You can find out more about health and social care here. If you have any enquiries about the Living Well team please contact