How Rebecca (Link Worker) has been supporting patients to regain their confidence post lockdown


As COVID-19 lockdown restrictions begin to ease Integrated Plus has been looking at ways in which we can adapt to meet people’s needs. A large percentage of the people that we work with have long-term health conditions, meaning that they have not left their home for several months due to shielding. Many live alone or do not have family and friends close by so their loneliness and need for social connection has been exacerbated by restrictions. 
As we are now in spring and the sunnier weather is approaching, we have seen an increase in people wanting to leave their homes, for social connection, exercise and sunshine, however they lack the confidence to walk out of the front door. Integrated Plus staff have been supporting these people by doing supported walks aimed at supporting both physical and mental health. Here are some recent examples: 
Mrs A is an elderly lady who lives alone and told me that she has not left her home independently in nearly 2 years. She told me that her goal is to be able to walk to her local corner shop, but she lacks the confidence to go on her own. Following this conversation, I accompanied Mrs A to her local corner shop on two occasions. Since those two walks Mrs A has been on a further two walks to her local shop with her gardener and cleaner. Being able to walk to the shop means that Mrs A has reconnected with the shop assistants and is gaining confidence to go back groups that she attended prior to lockdown. 
Miss B is a young girl who has autism, since the start of the pandemic she has not left her home independently. During a telephone conversation Miss B expressed to me that she wanted to walk into her local town but lacked confidence. I accompanied Miss B on a supported walk into her local town and visited several book shops and showed her where her local library was based. Miss B has since walked independently into her local town and has visited the local library to enquire about joining a book club. 
Mrs C is a recently bereaved lady with multiple health conditions. Due to her health and restrictions, she has not been able to leave her home in several months. Mrs C expressed to me that she is keen to start exercising by walking around her small carpark. I met Mrs C for a walk around her carpark and she said she enjoyed getting out of the house for a chat, exercise and some vitamin D! We are still working with Mrs C and hope to connect her with a volunteer befriender who can offer long-term walks and companionship. 
As we emerge from COVID-19 into what feels like a different world, social prescribing plays an important role in supporting the governments COVID-19 mental health and wellbeing recovery action plan (April 2021) and interventions such as connecting people with their community, physical activity and access to outdoor spaces play a key role in improving people’s physical and mental health.   

Rebecca Woodall – Senior Social Prescribing Link Worker (Halesowen PCN)

Client X supported to maintain independence and improve wellbeing

X was referred to Integrated Plus in June 2020. At the time, X was living in a B&B and had mobility and physical health needs that could not be met, due to having to use shared facilities such as a bathroom and kitchen area. X was also having issues with his memory and was extremely isolated.

When the Senior Social Prescribing Link Worker first contacted X, X gave consent for them to speak to his daughter in law, as he was struggling with memory. The Senior Social Prescriber talked to the daughter in law to learn more about X’s struggles and challenges and a plan of action was developed.

The Senior Social Prescriber referred X to Adult Social Care and to Housing Support. Due to X’s support needs, X was allocated a worker from Housing Support. Adult Social Care, Housing Support and Integrated Plus supported X to find appropriate housing in an age exclusive setting with other residents of a similar age. For the first time in years, X had access to his own kitchen, bathroom, living room and bedroom.

X was given some hours of care to help him to maintain his independence. Integrated Plus and Housing Support worked together to obtain a new cooker and fridge freezer for X and supported the family with setting up direct debits for his bills. Integrated Plus also supported with access to a memory assessment with the doctor’s surgery and X’s memory issues are being monitored on an ongoing basis.

The Senior Social Prescriber also supported X to apply for Attendance Allowance, which made a huge different to his ability to pay for the extra help he needed e.g., someone to help with cleaning his flat.

X’s daughter in law reported that the difference she had witnessed in X was ‘astounding’. Due to X feeling happier with his living situation, his daughter in law commented that his relationship with his family had ‘improved, as it’s more enjoyable to spend time with him in his own flat’.

X’s daughter in law said:

Integrated Plus have been amazing. Their help and advice have been valuable and most appreciated. As a family who never claimed benefits or applied for council housing, we would have really struggled without their help. They have been fantastic easing the pressure on us and they offer an invaluable service to the community. We cannot thank them enough! Thank you so much for your help, support, and guidance.

Dudley CVS commission Riverside Stourbridge CIC to deliver new outdoor social prescribing activities

Riverside House is a beautiful and ecologically diverse site in Stourbridge which runs alongside Stourbridge canal. Riverside House is in the process of transforming the 19th century ironworks area into a heritage centre with gardens, a restaurant, crafts shop, woodland and workshops but also a place where people feel included and bespoke opportunities are provided.

Much of this work is now well underway. Our capacity building team at Dudley CVS initially helped Riverside Stourbridge to get set up as a CIC, supported them with planning, building their vision and securing funding and it is fantastic to see the progress being made. The project works with a wide range of individuals from diverse backgrounds and supports them to learn new practical skills through the conservation and preservation of the estate.

In the winter of 2020, Clare and Lloyd at Riverside Stourbridge CIC applied for funding from our voluntary sector social prescribing fund. The fund makes it possible for new activities and services to be set up and delivered to meet the needs of our Integrated Plus High Intensity User social prescribing clients, who frequently attend A&E or call 999. Their application was successful and they’re now delivering three different workshops including copper & willow weaving, blacksmithing and green woodwork.

Ami is a client accessing the High Intensity User social prescribing service, after hearing about the workshops she was keen to try blacksmithing as she enjoys being outdoors and learning new skills. Ami attended the six week course and thoroughly enjoyed every session, she showed her Link Worker how she had made a plaque for her home to hang her keys on and how she has personalised it. Ami was able to recognise within herself how the workshop had built her confidence and helped her overcome her fear of new places.

“I attended the Blacksmithing course at the Riverside House Project and I loved it! Not only did I get expert and friendly tuition in a totally new skill I had never tried before, but the guys shared their vision and dreams for the Riverside House site during the sessions and got me excited for the future of the project. All the volunteers and leaders were friendly and welcoming, always encouraging and helped me feel confident in something I had never done before! Looking forward to joining with more projects and seeing the way the RHP develops and expands in the coming years.” Ami

To find out more about the other fantastic work that Riverside Stourbridge CIC deliver, click here.

To find out more about our voluntary sector social prescribing fund please email

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Carving spoons at a green woodwork session
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Making copper bowls

Client X supported to unlock artistic talent and reduce hospital admissions

Client X was highlighted as a potential person that we could support, within the last 12 months he had been admitted to hospital on 19 separate occasions. During the Covid-19 pandemic I made contact with him over the telephone, built up a rapport and carried out a holistic assessment.

Client X is an older male and he had become extremely lonely since his wife had been taken into a care home. He lives in supported housing but due to Covid-19 all the activities had stopped.

I identified that Client X was really struggling with loneliness and this was not helping his long-term health issues, this resulted in his admissions to hospital increasing. I needed to look into how social prescribing and the HIU service could help alleviate the pressure on the hospital, especially during the pandemic but most importantly help and improve the health and wellbeing of Client X.

During our many telephone conversations, Client X told me that he is artistic and loved painting but could not afford to buy supplies. I was able to allocate Client X a personal health budget in order to purchase some art materials such as paints, canvas’s etc.

I’m pleased to say that over the last few months this has given Client X a sense of purpose, he now paints pictures and gives them away to his carers and to other residents, improving his social life. His hospital admissions have dramatically reduced.

I feel that something as simple as being able to allocate client X a personal health budget has made a huge different to his mental and physical wellbeing and he no longer has a need to go to hospital.

Here is a photograph of a recent painting that Client X sent to me:

Kelly Rea – HIU Link Worker

Tea Time Treats for Halesowen residents

In 2015, Halas Homes took over the running of a local café called Coffee Cups in Halesowen. The cafe was a social enterprise where people with learning disabilities could learn and develop skills in a real, commercial working environment. Coffee Cups quickly became a very important part of the local community and was considered to be a ‘community cafe’.

Coffee Cups was a much loved place to visit by local residents (including one of our clients, Mr X). Mr X is in his 80s and was referred to Integrated Plus by his GP due to long term health conditions and loneliness. When the Link Officer (Sue Bloomer) visited Mr X she realised that he could no longer easily manage to walk to Coffee Cups unaided, and asked the Link Support Worker (Becky Woodall) to take Mr X to a local mobility centre to help him look at mobility scooters. After looking at what was on offer Mr X decided to buy a mobility scooter there and then! He used it to visit Coffee Cups regularly and got to know all the staff and customers there. It has also enabled him to be more independent and visit other local shops.

Unfortunately, due to the Coronavirus outbreak early in 2020, Coffee Cups was forced to shut its doors, leaving Mr X with little social contact with others, less chance to get out and about, and reliance on his own cooking.

However, Halas Homes has now received some funding to use to benefit local people and has used this to set up ‘Tea-Time Treats’. The staff deliver free tea, coffee, soup and sandwiches to those identified as elderly and isolated. Integrated Plus has worked with the Project Coordinator to identify people who would benefit from the new project, and Mr X is delighted to receive support from this new initiative. 

Quote from Jo Bennett about how the project is going:

We have had a positive response and fabulous feedback from the residents we are supporting so far. It is great to see the project continuing to grow week by week.

Meeting the residents and having the opportunity to have a chat with them when we deliver their refreshments is a fabulous way to keep all our spirits up. The warm welcomes we get are heart-warming, especially during these difficult times.

Staff on their team time delivery rounds

Jenny receives support with her finances, mental health and enjoys a brighter Christmas

Our client, Jenny, lives with her partner and 3 children. She is a full time teacher at a local secondary school and her husband currently works part time due to the coronavirus. Her husband was made redundant a day before her youngest was born a few years ago – the stress of this resulted in him having a breakdown and struggling to get re-employed. Since then, they have acquired debts that equal into their thousands and have had trouble paying them off. Jenny was referred to Integrated Plus initially for support with their financial situation and the crisis point that was nearing.

At the time of our support, Jenny was off sick from work due to the stresses of the above. Jenny agreed for a referral to the Arts Of Change for counselling, as she felt that she was on the edge of her own breakdown with having to care for her children, her father and her husband. We also sent information on the Debt Life Centre in Stourbridge – who could go through the debts one by one and offer to sort out a payment plan.

At the time of our referral, we had had a generous contribution of ASDA vouchers to Dudley CVS for people who were struggling to afford food or necessities at the time, especially due to the financial burdens of the pandemic. I offered one of these to Jenny and she accepted this support.   

When I called back to Jenny a month later to see how things went, she was really happy with the ASDA voucher. It meant she could buy items that they had wanted for a while, and buy foods in bulk that they needed. This helped to take the edge off the weekly shop, which can become quite pricey for a family of 5!

As a service, we had been offered 5 places for families who were struggling financially to have a Christmas dinner hamper sent to them for Christmas time. This generous offer was made by The Christmas Lunch Project who’s mission is to support families with children who cannot afford to buy all of the ingredients to cook a Christmas Lunch on Christmas Day. Jenny agreed to this, and was very grateful for the offer – “To be offered something like a Christmas Hamper by a service is truly heart-warming. Especially as my father in law who passed away not long ago, would have usually paid for this in recent years.”

Jenny explained that they had managed to find some money to pay off their debts, by the sale of her father in laws property. Although this hasn’t paid off all of the debts, they are in a better situation now where the important debts have been paid and can manage to pay monthly sums for their other debts.

We also offered the support of the voluntary sectors Operation Santa project, which take’s place every year at Christmas time in Dudley. Generous donations are gifted to the project by individuals, organisations and businesses – in order to help the children of vulnerable families or families in need at Christmas time. Jenny agreed for us to refer her into this, and presents were sorted for her 3 children ready for Christmas. Here we have been able to take the edge off another expensive time of year!

“The sale of the flat, coupled with the generosity from the voluntary sector projects like the Christmas lunch project and Operation Santa, has helped us enormously when needing support at such a difficult time financially”.

Jenny has had two face to face sessions with an Arts of Change counsellor and has found this really helpful:

I needed support because I was living in a state of panic. The counsellor here helped me with techniques and coping mechanisms to deal with panic. I am now also keeping a journal for when I have a lot of problems that I cant seem to pin down in my brain. This allows me to rationalise them and makes them clearer when I put pen to paper. The counsellor has also allowed me to talk out difficult conversations that I have had in my life, for example arguments with family members. I have then been able to see them from different perspectives. Being offered the option of seeing a counsellor face to face, especially at the time of the Covid pandemic has been really helpful. It has made the whole process more meaningful for me”. 

Jenny’s experiences on the help we offered:

“When we first ran into trouble, I thought there was no way we could get support. I was earning and so was my husband so we couldn’t claim any benefits or get any welfare grants – however in reality this money was going straight towards paying off our debts. We had relied on extra bits of income before Covid, for example my partner working longer hours and I was offering one to one schooling tuition to pay for our weekly expenses. Since covid – this extra bit of income had stopped. My husband could not find the extra work and I was unable to go into other people’s homes to teach. This really affected us, and thought we would have to sell our house in order to manage.

I was able to speak to my GP at the surgery, who then referred me onto the Mental Health nurse as well as Georgia and Gary at Integrated Plus. The support (mentioned above) that was offered to me was such a great help. It really made me feel that there was such a joined up approach within the services. I really didn’t know which way to turn and I have been helped so much by each and every service that supported us. We are now in a better position, and although there are still things to overcome, it is so nice to know that there are people out there who are willing to help”.

Georgia Pearsall & Gary Hastie

New outdoor course commissioned to improve “mental toughness” of HIU clients

Natasha, Vicky and Ami were all referred to the HIU project due to their high hospital admissions and 999 call outs. Each one of them had their own mental health issues that they were trying to work through. They always discussed how they felt they had low confidence and low self esteem and this impacted negatively on their mental health on a daily basis.

They were all approached and asked if they would like to attend our new Challenge Academy social prescribing 5 week course. The course was designed to work on developing mental health awareness, building resilience, improving mental well-being, building confidence, developing self-esteem and positive self-image. Challenge Academy CIC have an excellent understanding of social determinants of mental health and through the course focus on goal-setting and personal achievement, changing unhealthy thinking and developing a positive mind-set.

They all said they would give it a try but were very apprehensive. On their first day they met with their course instructors Chris and Gregg who would deliver the course over the 5 weeks, they got to learn all about each other and what the course would entail over the coming weeks. As the weeks went by and they continued with the course activities they were able to learn and develop through participating in outdoor art sessions, orinteering, team building activities and much more.

Over the course of the weeks it was very easy to see the positive change in all of the participants. Their confidence increased, they felt better in themselves and were wanting to push themelves out of their individual comfort zones. They could easily identify the marked inprovement in their own mental wellbeing and were noticing changes.

Vicky (HIU client) said “it’s great fun and confidence boosting, it makes me feel good I don’t even realise im doing exercise! The staff are really friendly”

Natasha (HIU client) said “staff are really encouraging and push you out of your comfort zone. The team building exercises are fun and really help to build your trust and confidence.”

The three clients have formed a close knit friendship through attending the sessions and would always give each other encouragement in all their tasks and pick each other up when they were struggling. This friendship has continued outside of the course and on weekends they now meet up and go shopping, for a coffee or visit one another.

Speaking with the clients it is clear to see the improvements, not only through their admissions and ambulance call outs drastically reducing but also through their own personal wellbeing. They all advised that they didn’t find it easy but felt with each others support and the support from the course they could do anything that was asked of them, this even included completing activites in record time by working together as a team and solving the problems they were given.

Each individual is now looking forward to taking the skills they have learnt from this course and using them in their future.

Ami (HIU client) said “There is a great atmosphere, friendly staff who really challenge you but make you realise what you’re capable of when you put your mind to it.”

Danielle Giles – HIU Link Worker

Barbara helped to stay in her own home

Barbara was referred to Integrated Plus by her GP at Lion Health.  She had some household issues she wanted to resolve and suffering with depression.  When Barbara met Georgia, the Locality Link Officer for Stourbridge, Wollescote and Lye, she went into more detail as to how she was feeling.  Barbara said she was upset and depressed because there was some uncertainty about her having to move from her property due to access and safety issues.  One of the main issues was Barbara did not have a cooker and her social worker identified that her current set up in her kitchen was a safety risk.  Georgia discussed this with Barbara and her social worker and said we could support her with applying for a Grant for a cooker which would make her property safer and more accessible.  Barbara also said she would like support with her garden which had become overgrown and unmanageable.   

Barbara has osteoporosis, brittle bones, dry macular degeneration and glaucoma.  She is also a wheelchair user and has volunteered at Beacon Centre for many years.  Barbara is a real inspiration to everybody she meets and is always willing to help others, she travels to the Beacon Centre every day on her mobility scooter come rain or shine.  She volunteers with craft groups and is always there to welcome members and volunteers.  Georgia tasked Gary, the Link Support Worker to make contact with Barbara to look at possible grants for a cooker.  Gary discussed this with Barbara and it became apparent that she would need a cable fitted as well as an electric cooker.  He applied for a grant from The Reginald Unwin Charity and this was successful but only for the amount of a cooker and not for the cable and fitting.  Barbara could not afford to pay for the rest so Gary then applied to Badley Memorial Trust who work closely with Geoff Hill in Amblecote and they agreed to fund the electric cable and fitting.

Gary met Barbara a couple of weeks later to do a review and said she was delighted with her new cooker, she said: “The cooker has made a big difference to my life, I haven’t had a cooker for nine years, I use it regularly to cook healthy food.” 

This has also enabled her to stay at her property alleviating the stress of a potential move from the home she loves.  Barbara also mentioned to Gary when they first met that she would like support with her garden which had become overgrown and difficult to manage.  Unfortunately, this was difficult to accomplish due to the lockdown, however Barbara was able to get support with this from her circle of friends and other volunteers at Beacon Centre and they have supported her to regularly tend to and maintain her garden.  The Beacon Centre opens again soon and Barbara is eagerly awaiting to be reunited with her friends and fellow volunteers.  

Barbara with her new cooker