We are a specialist team providing preventative services to individuals over 55 years of age in the community across South Staffordshire.

The service supports adults within their own home who have been identified as having mild to moderate frailty. The aim of intervention is to proactively manage the deterioration of frailty by taking a preventative approach and help individuals to stay well, live well, and age well.

What is Frailty?

Frailty is related to the aging progress where the body gradually losses it’s in-built reserves leaving us vulnerable to changes in health triggered by infection, falls, and changes in medication for example. It includes social and emotional wellbeing and an ability to bounce back from things and withstand and delay health decline for longer.

Staying Well Assessment

People who are referred to the service have been identified as those with mild to moderate frailty. One of our Staying Well Facilitators will then visit the person at home and carryout a holistic assessment looking at General health, medications, social support, cognition / memory, mood, mobility, functional performance and functional independence.

Case Studies

We currently have two case studies that you can read to find out more about the service. These case studies focus particularly on the use of technology to support those using our services.

Following Assessment

We support individuals to understand and manage their own health and wellbeing, promote healthy living and behaviours, signpost and onward referrals are also made. Links into local communities are also made to reduce isolation.

The team is made up of nurses, registered mental health nurses, occupational therapists and occupational therapy assistants. We also work alongside consultants and pharmacists.

We work closely with Community Connectors and Social Prescribers to link people to their local communities.

Following the assessment, personalised plans are provided and monitored, and followed up by the Staying Well Facilitator at six weeks and six months following the initial assessment.

It is hoped that by delivering a preventative approach to healthcare, enabling individuals to manage their own health, and through early intervention we will increase successful aging within the community.

Staying Well Advice

Eating Well

Eating well means you’re more likely to feel healthier, stay active for longer and protect yourself against illness. Advice and support on eating well can be found on the Age UK website.


Preventing Falls

Falls not only result in possible injury and long term complications, but can also lead to a loss of independence and confidence. Further information regarding falls prevention is available from our Falls Prevention Service.

Falls Assistant provides information regarding falls prevention and enables you to develop your own action plan to avoid and prevent falls.



Urinary incontinence is the unintentional passing of urine. It's a common problem thought to affect millions of people. Further information regarding causes, treatment and prevention can be found on the NHS website.


Mental Wellbeing in Older Age

Feeling worried or having a low mood are not just part of getting older. As we move through different stages of our lives mental health can change too as our circumstances change. Information, support and advice can be found on the Age UK website.

We have some self-help guides for common mental health issues.

Staffordshire and Stoke-on-Trent Wellbeing Service delivers a range of evidence-based psychological therapies for people aged over 16 with common problems such as anxiety disorders and depression. You don’t have to be referred by a doctor. You can refer yourself by simply phoning to make an appointment 0300 303 0923 (Monday to Friday, 9am - 5pm).



As we get older it is not uncommon to notice changes in our memory. Further information and guidance about memory problems and advice regarding staying healthy to maintain your memory are available on the Alzheimer's Society website.


Maintaining independence

Staying Active

General advice about remaining independent can be found onthe Independent Age website.


Daily Living Equipment

Daily living equipment generally refers to items of equipment to help people with everyday tasks and to help them live their lives as independently as possible.


Useful Websites

Staying Well Service Contact Details

Phone numbers, fax and email


Staying Well Service,
Merlin House, Etchell Road,
B78 3HF