Living Well in North Yorkshire

Our coordinators work with people in need to reduce loneliness and isolation, increase participation and support you to be independent.

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  • Helping you to make small changes to improve your quality of life

Living Well aims to improve the health, wellbeing and independence of adults. Our coordinators work with individuals and their carers who are isolated, vulnerable, bereaved, lacking confidence, or perhaps on the borderline of needing health and social care services. Instead, we help them to access their local community, and support them to find their own solutions to their health and wellbeing goals. This helps to reduce loneliness and isolation, and to prevent or resolve issues for people, including preventing hospitalisation.

Living Well works alongside public health services and stronger communities within the council, as well as NHS clinical commissioning groups, district councils, and voluntary, community and social enterprise organisations.

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; and
  • to provide practical advice, information and support.

What do Living Well coordinators do?

Living Well is a personalised service, and what the coordinators do varies with each individual. They 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;
  • work with individuals to achieve the outcomes that are important to them;
  • help them make simple changes to their lifestyle and their home environment, to help people be more active, improve mobility and 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 working with individuals, Living Well coordinators are extra eyes and ears in the community. They provide feedback on the quality and availability of low level support in the community to health and care commissioners. They also support the work of the stronger communities team to identify gaps, needs and community assets, providing information for the community directory. They are 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 benefit?

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

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

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

You can read below the stories of some of the people Living Well has worked with.

Phyllis was a 67 year old woman who lived on her own. She contacted us explaining that she needed some help. She had been unable to work for a number of years due to ill health. She had suffered two heart attacks and as a result had to have numerous operations and has been left feeling very breathless. This had resulted in her becoming more and more isolated in her own home lacking the confidence to go out. She had no family nearby and her friends did 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 struggled to maintain her home and it was getting her down.

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

She has felt more motivated to get things done and 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 was unable to drive anymore and had had to submit his driving licence to the DVLA. He missed driving to popular areas in the countryside and going for a walk on his own or bird watching.

Mr Jones had a bus pass and would take a bus journey, however, sometimes he was unable to understand the bus timetable and would just wait at the bus stop until one turned up.

Mrs Jones worried about Mr Jones when he went out alone which means she never got a break from her caring role; she got very distressed if he didn't come back at an agreed time.

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

What did 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 was potentially unsafe so wanted 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 found it difficult initially to engage with strangers and found that if too many people are talking at once he was 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 has been enjoying going out walking in a safe environment and making new friends and contacts in the community leading to potential new leisure opportunities. He was now aware of bird watching opportunities in the area and was making 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 was a young autistic man in his twenties who lived on his own in a studio bed sit. His parents, who had always been a constant support to him, had recently moved out of the area and his mother was worried that her son could be socially isolated.

What did 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 autism was 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 attendee at a local weekly social group and 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 was 78 years old and lived with his wife. Since his stroke last year he had been struggling with movement down the right side of his body and grasping with his hand. He had lost a lot of confidence in everyday pastimes that he once enjoyed such as painting, woodwork and card making. He did not enjoy groups and felt very passionate about having his independence to do things for himself. He had quite a lot of support from his wife but he didn'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. 

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 was struggling 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 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 was important to him, with six children and three grandchildren coming for tea every week. Albert often sat in a separate room and did not engage unless anyone came 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 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 lived alone and felt isolated in her home after the loss of a loved one, and with her children having their own lives. She had lost some of her mobility and had 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 said "I now know that there really is life after 80".

Doreen was 84 years old and lived alone. Her only daughter lived far away. She had recently been diagnosed with dementia and the friends that she used to care for had passed away. She felt very lonely.

How did Living Well support Doreen?

Living Well supported Doreen to build her own confidence; the coordinator 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 had helped her to build her confidence and her social connections (mp3 / 1 MB).

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

Referrals to Living Well

You can refer yourself to Living Well directly.

You can ask for a referral to Living Well for a person in need if you are:

  • a council employee;
  • a worker from outside the council; or
  • a partner organisation (such as the NHS).

Professionals, workers and practitioners can download our  information pack for partners (pdf / 599 KB).

We will always ask the person's consent before proceeding.

It is not certain that the person will be referred to Living Well. Our specialist social care workers at the customer service centre will be able to talk through the situation with you and decide on the best course of action. This could be Living Well, or it could be another service such as social carePeople who have been assessed as having ongoing care and support needs, and who are already receiving a health or social care service, can not use the Living Well service.

Contact us


Frequently asked questions

There is no list of all the ways a coordinator can help, as this varies widely according to each person's needs.

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 include:

  • support to gain or improve practical skills;
  • access to specific support available from local voluntary agencies such as befriending, shopping, transport or advocacy;
  • 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;
  • help to get online either in the home, or at a library or internet cafe;
  • help to find a volunteer role or become active in the community;
  • advice on healthy living and sign posting to lifestyle services such as stop smoking and exercise.

The Living Well coordinators do not provide services such as befriending, shopping or cleaning directly themselves, but they will support people to find and access these services.

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

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 coordinator will help them to access the service using the organisation’s own referral process. 

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.