Ageing Well in Herefordshire means supporting older people to live safe, independent and fulfilling lives for as long as possible, in the place they call home, surrounded by familiar people, routines and communities.
As the population ages, more people are living longer with multiple long‑term conditions, frailty or dementia. At the same time, older people consistently tell us they want support that is timely, joined‑up, respectful and focused on what matters to them, rather than being moved through services as needs escalate.
Our approach to ageing well reflects national direction and local need. It places prevention, reablement and continuity at the centre of commissioning, while recognising that high‑quality residential and nursing care remains essential for people whose needs can no longer be met at home.
Context and vision
Our vision is that older people in Herefordshire experience support that:
- Is easy to access, wherever they live
- Focuses on independence, dignity and choice
- Supports recovery and confidence following illness or crisis
- Helps people remain connected to family, friends and community
- Provides safe, high‑quality care when living at home is no longer possible
Living at home, safely and well, remains the default ambition wherever appropriate. When additional support is required, it should be proportionate, flexible and focused on helping people regain or maintain independence, rather than creating long‑term dependency.
Where care home or nursing provision is needed, it should be planned, compassionate and delivered through strong partnerships, providing stability for residents, families and the workforce.
How we will achieve it
Focusing on experience and outcomes
Support for older people will increasingly be commissioned around outcomes such as independence, quality of life, dignity and safety. Reablement‑first approaches will be embedded across pathways, supporting faster recovery and reducing avoidable long‑term care.
This approach reflects the aims of Services in Your Home, ensuring that care is built around people's strengths and promotes independence wherever possible.
Whole‑life thinking
We will work proactively with health, housing and care partners to ensure older people have the right support at the right time. This includes access to reablement, home care, assistive technology, housing adaptations, extra care housing and residential or nursing care when appropriate.
Planning ahead and coordinating support will help people avoid crisis and reduce unnecessary transitions between services or settings.
Forward‑thinking partnerships
We will continue to strengthen partnerships with home care providers, care homes, housing partners, developers, the NHS and the voluntary and community sector.
Through the Care Home Partnership, we will support the delivery of high‑quality residential and nursing care, improving workforce stability, quality and sustainability while ensuring the system can respond to increasing complexity.
Strengths and assets
We will build on the strengths of individuals, families and communities. Community‑based support, voluntary organisations and social connection play a vital role in reducing isolation and sustaining wellbeing.
Technology‑enabled care will be used appropriately to support independence, safety and reassurance at home.
Co‑production
Older people and carers will be actively involved in shaping services, pathways and commissioning approaches. Their lived experience will continue to inform service design and improvement.
Outstanding quality
We will work with providers to deliver compassionate, respectful and high‑quality support, both at home and in care settings. Workforce continuity, skills and supervision will be central to quality, recognising the strong link between stable care teams and good outcomes.
Direction of travel
The direction of travel for ageing well is towards:
- Greater use of prevention and reablement‑first approaches
- Expanded, high‑quality home‑based care aligned to complexity
- Reduced reliance on crisis‑driven admissions to long‑term care
- Stronger, planned pathways into residential and nursing care when needed
- Partnership‑based commissioning that support workforce stability and quality
This approach aims to improve outcomes for older people, provide confidence and clarity for providers, and ensure the long‑term sustainability of the care system in Herefordshire.
Priority 1: Prevention, reablement and timely support
What
A strengthened home‑first approach for older people, ensuring prevention, reablement and recovery are the default responses wherever it is safe and appropriate to do so.
This includes:
- Early, strengths‑based conversations from first contact
- Timely reablement and recovery‑focused support
- Home‑based care that adapts to changing needs and promotes independence
Why
Older people consistently tell us they want to remain at home for as long as possible, with support that focuses on what they can do, not just what they cannot.
A home‑first approach:
- Supports dignity, confidence and wellbeing
- Reduces avoidable hospital admissions and long‑term care placements
- Improves outcomes following illness or crisis
- Supports carers and family networks to sustain caring roles
As the population ages and complexity increases, prevention and recovery‑focused support are essential to the sustainability of the care system and to improving outcomes for older people.
How
We will support independence and recovery for older people by:
- Embedding strengths‑based, outcome‑focused conversations at every contact point
- Ensuring reablement‑first pathways are available following illness, hospital discharge or changes in need
- Commissioning flexible home‑based care that can increase or reduce as people recover or stabilise
- Strengthening integration with health partners to support timely discharge and recovery at home
- Using reviews to support recovery, reduce dependency and reshape support where this is safe and appropriate
- Targeting early help at key life events, including bereavement, diagnosis, falls or changes in mobility
- Expanding access to equipment, adaptations and technology‑enabled care to support safety and independence at home
- Working with the voluntary and community sector to reduce isolation and promote wellbeing
- Ensuring older people and carers are involved in shaping their support and recovery goals
Priority 2: Community based support, inclusion and independence
What
A planned, partnership‑based approach to residential and nursing care for older people whose needs can no longer be safely met at home, ensuring care is delivered with dignity, quality and continuity.
This includes:
- High‑quality residential and nursing care aligned to increasing complexity
- Dementia‑capable provision across the whole care journey
- Clear pathways from home‑based support into long‑term care when required
Why
While living at home remains the default ambition, we recognise that for some older people residential or nursing care will be the most appropriate and supportive option.
Unplanned or crisis‑driven admissions to care homes:
- Create distress for individuals and families
- Undermine continuity and quality of care
- Increase pressure on the workforce and providers
- Lead to poorer outcomes and higher system cost
A planned approach to residential and nursing care:
- Improves outcomes and experience for older people
- Provides certainty and stability for families
- Supports workforce continuity and quality
- Enables providers to plan, invest and sustain high standards of care
How
We will strengthen planned residential and nursing care for older people by:
- Developing and embedding the Care Home Partnership approach, focused on quality, stability and shared responsibility
- Working with providers to ensure residential and nursing care is dementia‑capable, trauma‑informed and responsive to increasing complexity
- Prioritising planned admissions and pathways, reducing reliance on crisis placements wherever possible
- Aligning residential and nursing care more closely with home‑based support, reablement and Discharge to Assess pathways, ensuring smooth transitions
- Supporting continuity of care by reducing unnecessary moves between settings
- Strengthening quality assurance, safeguarding oversight and improvement support
- Using commissioning to support workforce stability, skills development and retention, recognising the link between staff continuity and quality of care
- Involving older people and families in decisions, ensuring care homes are entered as a positive and informed choice when home is no longer suitable
Priority 3: Safe, high quality homes and care settings
What
The development and strengthening of short‑term recovery, step‑down and intermediate support for older people, enabling timely discharge from hospital, recovery at home where possible, and avoidance of unnecessary long‑term care placements.
This includes:
- Step‑down and recovery beds aligned to Discharge to Assess pathways
- Short‑term accommodation with care
- Reablement and time‑limited support focused on recovery and independence
Why
Following illness, injury or hospital admission, older people are most at risk of losing confidence, mobility and independence.
Without timely recovery‑focused support:
- People can become dependent on long‑term care unnecessarily
- Hospital stays are extended or delayed discharges increase
- Individuals and families experience anxiety and uncertainty
- Pressure increases across acute, community and social care services
A strong recovery and step‑down offer:
- Supports people to regain independence and return home safely
- Reduces avoidable admissions to long‑term residential or nursing care
- Improves system flow and supports NHS discharge
- Provides better outcomes and experience for older people
How
We will strengthen recovery and step‑down pathways for older people by:
- Expanding and improving access to step‑down and short‑term recovery accommodation aligned to Discharge to Assess pathways
- Ensuring recovery services are time‑limited, outcome‑focused and reablement‑led, with clear expectations about progression
- Improving coordination between hospitals, community services, care providers and housing partners to support timely discharge and recovery
- Aligning recovery pathways with home‑based reablement, ensuring smooth transitions back home wherever possible
- Reducing reliance on long‑term placements being used as default solutions following hospital discharge
- Using reviews at the end of recovery periods to support independence and avoid unnecessary continuation of formal care
- Working with providers to ensure recovery services are delivered by skilled, stable staff with the right mix of clinical awareness, reablement expertise and person‑centred practice
- Involving older people and families in planning recovery goals and next steps, ensuring clarity and confidence at points of transition