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Middlesbrough Integrated Services model

Middlesbrough is getting more support to tackle the spike in coronavirus cases. Find out more about the extra support.

A new integrated model launched on 1 April 2021, and brings together support for Middlesbrough residents who may have experienced or are experiencing:

  • domestic abuse
  • homelessness
  • substance misuse

The integrated model consists of a number of specialist support services which have been commissioned by Middlesbrough Council. The Middlesbrough integrated model will mean better information sharing, easier access to the right support,  and services working together more effectively. In short, the support a person receives will be 'joined up'. It recognises people have different needs, so will offer different levels of support based on individual circumstances.

We have considered good practice from other areas to help us design this new model especially for Middlesbrough. We're also responding to learning from recent Lessons Learned Reviews and Domestic Homicide Reviews, and putting recommendations into practice. Given the increase in drug-related deaths, domestic homicides, and high harm and vulnerability experienced by some of our residents, everyone involved in the integrated model is committed to this new way of working, which will help make a difference for residents who need it most

For more information or referrals, please call 01642 726800.


The integrated services model in Middlesbrough is a range of high quality specialist support services which have been commissioned by Middlesbrough Council. The services will be working with dedicated council teams to provide ‘wrap around’ support to Middlesbrough residents.

People who may have experienced, or are experiencing, interrelated issues connected to domestic abuse, homelessness, and substance misuse will be able to get support through the model. It will make sure the support a person gets is based on their individual needs and takes into account their past experiences.

The integrated services model recognises that people’s needs vary. It will offer different levels of support to respond effectively to people at the earliest opportunity.

It’s vital that all the services work well together to support local people. The integrated services model will allow better information sharing, make accessing services easier, and help services to work together more effectively. In short, the support a person receives will be ‘joined up’.

The model is not about changing what already works. It’s about building resilience and capacity between Middlesbrough Council and specialist services so we can work with residents more creatively. We’ll help people to overcome barriers which may be preventing them and their family from being able to reach their goals, be safe, or cope and live well day to day.

The model reaches out to communities, delivering in community venues which people may already know or use, and will work alongside a wide range of statutory and voluntary services.

It will make sure people who need help and support know exactly what is available, can easily access it, and can make informed choices about what happens to them next.

Above all else, the integrated services offer is about valuing positive engagement. We believe every single person is important, has the ability to change their life, and has a right to live safe and free from abuse. We want to establish meaningful and trusting relationships with people which will help make a difference to them, which in turn will help make a difference to Middlesbrough.

We’ve carried out Needs Assessments for domestic abuse and homelessness, and a consultation for substance misuse. We’ve listened, and talked, to a lot of services and people about what needs to change to improve systems and the way organisations work together. We’re also responding to recent Lessons Learned Reviews and Domestic Homicide Reviews, and putting recommendations into practice.

We have excellent services in Middlesbrough, but we recognise that some of our most vulnerable people have difficulty navigating the different services.

We know that it can feel daunting to take the next step and ask for help, and that sometimes even though people are being signposted to the right services, they do not access or stay in contact with the service. We’ve learned that often when people finally did reach out for help, it was when they were in crisis and at high risk. We also know that sometimes people who need help the most do not always access services, or when they do, they’re not able to get the right support at the right time. This was not always achieving positive or sustainable outcomes for the service user.

At Middlesbrough Council, we’ve started on a journey to change this. We have key statutory duties around domestic abuse, substance misuse, and homelessness, and while we want to make sure we meet those, we also want to make sure that the services we commission are able to work well and grow. This is the first stage of a long-term vision, to meet the needs of Middlesbrough people better together. Collaborating through the integrated model will help us to do this.

Key to this is listening and learning from those that really matter, the people, our services, and all our communities, as we want everyone to help shape this model.

The integrated model is for children, young people, and adults who may need support or help to access services relating to welfare rights, substance misuse, homelessness, and domestic abuse.

Integrating services so they’re connected will make a big difference to how quickly and effectively the services can respond to people’s needs.

The model will:

Improve the responsiveness of services. Integrating will allow the right service to establish contact and engage, at the right time.

Reduce the need for service users to repeatedly tell their story. Services will work together to share relevant information and reduce the risk of people having to re-share traumatic experiences.

Avoid people falling through gaps between services.

Increase people’s ability to build resilience and keep themselves and others safe. It's about making sure people feel connected and in control over the services they get, and letting them choose where, when, and how they access services.

Make sure people have a point of contact and someone they can trust, so even if they fall out of services, they can quickly reconnect without the need to tell their story repeatedly. If things are not going well they can reach out and quickly get the help they need.

Help people understand what help is available to them, and overcome barriers which might stop them being able to access a service.

Make sure no one is turned away from a service.

Allow us to build meaningful relationships with people and be creative in how we work them, so we’re responsive to their needs.

Give people greater control, and bring together services to help them achieve the outcomes which are important to them

Let people access support via the Core Team as long as they need

Services and roles which form part of the Core Team working for Middlesbrough Council

Key workers

Key workers working for Middlesbrough Council as part of the Core Team primarily work with people with multiple needs who may experience barriers/and or difficulty accessing services or provision.

Key workers are specifically for service users who may need more intensive, flexible, and coordinated support. The role of a key worker is to coordinate and provide a consistent point of contact for the service user. They’ll focus on building a relationship and understanding the person and their needs. This will help the service user to feel safe to navigate services, and address any social, practical, and emotional concerns they might have. They will also work with them in a trauma-informed way to help change their behaviours and attitudes, and increase their resilience to cope more effectively day to day.

A service user assigned a key worker is likely to be experiencing two or more of the following:

  • problematic alcohol or substance misuse
  • prescribed medication-assisted treatment
  • unstable accommodation and/or threatened with eviction
  • repeat referrals to MARAC or MATAC
  • barriers to accessing long-term stable accommodation
  • placed in temporary accommodation
  • financial deprivation
  • involvement in sex work or sexual exploitation
  • history of anti-social behaviour
  • no recourse to public funds
  • resistant to change
  • referred to Adult Safeguarding
  • referred to the Team Around the Individual Panel
  • experience of sexual violence
  • involvement with criminal justice system
  • loss of custody of one or more of their children
  • reporting of self-harm or suicidal ideation risk factors
  • mental health issues
  • adverse childhood experiences
  • physical ill health or disability
  • learning disability (where known)
  • rough sleeping

Key workers will:

  • listen to what works for the service user and their life
  • understand the service user and their needs
  • help the service user understand their options and choices, and agree what service they need and any goals they may want to set
  • help the service user share information, understand their needs, and put this together into a plan
  • help the service user decide which support they want to receive, and when and how they receive it
  • regularly review the support service users receive
  • help service users to put systems in place so they get help at an early stage, to stop things getting worse or becoming a crisis
  • keep service users informed about next steps
  • make sure service users have access to information, and offer support on how they can use that information, so service users can make decisions about the support they get
  • have oversight over personal records, which a service user can see at any time, and can decide who to share them with, and ask to any correct mistakes in information held about them
  • make sure information is given to service users at right time, provided in a way they can understand
  • if a service user needs to access a new service, the key worker will make sure their assessment and plan is passed to the service and respected, so the service user does not have to tell their story again
  • if a service user moves between services, make sure there is a plan in place for what happens next
  • if a service user moves across geographical boundaries, make sure there is support to transition

Housing Solutions team

The Housing Solutions team will work with a service user to help prevent homelessness. The team will assess their immediate and long-term housing needs, and develop a personalised housing plan to offer help and advice to access accommodation or solve the housing issue.

Welfare Rights team

The Welfare Rights team provides advice to people around matters including Housing Benefit, Disability Living Allowance, and/or rent support.

Independent Living Worker / Tenancy Support Officer

The Independent Living Worker (private rented sector) will develop and deliver an independent living programme with identified complex individuals to keep their accommodation, offer emotional support, and develop motivational skills to make sure they do not lose their accommodation because of a lack of independent living skills.

The Tenancy Support Officer (rough sleepers) is responsible for providing day to day delivery of a tenancy sustainment service. This includes the co-ordination of effective support, advice, and assistance to rough sleepers, former rough sleepers, and those at risk of homelessness to make sure they can keep their tenancies.

Specialist services which work with the Core Team and are part of the integrated model

Domestic abuse specialist services

My Sisters Place

Provide Protect and Support service for women, men, and children experiencing, or affected by, domestic abuse. This includes:

  • Independent Domestic Violence Advisers
  • domestic abuse support workers
  • community-based programmes, like the Freedom programme
  • Sanctuary Scheme
  • domestic abuse counselling service
  • children and young people therapeutic support service and young people IDVA service


  • access to refuge/safe accommodation in and outside of Middlesbrough

Substance misuse providers

The substance misuse services working as part of the model will offer specialist prescribing services and a residential rehabilitation facility for drug and alcohol treatment.


  • opiate substitute prescribing (including oral methadone)
  • opiate detoxification medication prescribing (Lofexidine)
  • methadone prescribing – maintenance and detoxification
  • buprenorphine prescribing
  • naltrexone prescribing
  • non-opiate based detoxification
  • naloxone prescribing
  • home/inpatient detoxification
  • relapse prevention

Recovery Connections

  • recovery support
  • recovery community support
  • trauma counselling service
  • volunteering and ambassador programme
  • residential rehabilitation programme
  • family and carer support
  • collegiate recovery programme

Supported housing providers

Supported accommodation:

  • Riverside (Stages Academy) - male and female single adults
  • Riverside (Hardwick House) - male and female veterans
  • Thirteen - Penrith Road (families), and emergency crash pad
  • Changing Lives - male and female young people, and emergency crash pad
  • Home Group - Single Key (male and female young people)
  • North Star - North Star and Hestia (vulnerable women), and emergency crash pad

The integrated offer is working across a range of services, in and outside of the integrated model. Service users have a choice about who they work with and when they see services. This means there will be multiple access points and ways to contact a service, so service users can choose how and where to work with a service. There are some instances where a service user will access specialist services directly, but there is also a duty rota in place delivered by Core Team key workers, which can respond to enquiries, arrange appointments, or see someone face to face that day. More information about where people can drop in and have face to face appointment will be available here, and shared with service users and organisations, once coronavirus restrictions have ended.

If service users want to see someone in a different safe space, or need a home visit, this can also be arranged.

Service users can also still access services specifically relating to their needs, like domestic abuse or homelessness services, or arrange contact with the integrated model via a service they already know and are working with.

People can get in touch with the service by calling 01642 726800, emailing, or dropping in for a duty appointment.

People can refer themselves into the service, or someone can make a referral on their behalf. As soon as this happens, a key worker from the Middlesbrough Council Core Team or a specialist service will get in touch so we can understand what they need.

Once the service user has been allocated a named key worker, they’ll be given with contact details and a single point of contact if needed.

An agency can refer a potential client to the integrated model via phone or using the referral form. They need to have the client's consent before they do this.

Both options are available via the Middlesbrough Council Core Team, depending on what the service user prefers. During the week, they’ll be able to drop in and get the support they need on the same day if they choose. Alternatively, they can ask for a planned appointment at a time and place convenient to them.

Those accessing specialist services, like My Sisters Place, can do the same, but will need to phone or check the service’s website for opening hours.

There is also rapid access to specialist services for out of hours emergencies, like someone who does not have a place to stay or sleep that night, or who needs refuge accommodation.

During working hours, services will be available between the hours of 9am and 6pm, Monday to Friday.

Homelessness services are available 24 hours a day. If someone needs accommodation after 5pm, they can call the emergency out of hours number on 01642 726800 or 0800 1303 3067.

Domestic abuse emergency accommodation is also available 24 hours a day, by calling Harbour Support Service on 0300 020 2525.

The service user works with someone who can listen and help develop a plan, so they can make informed decisions about what service they need to access. It will help them, at their own pace, discuss what is important to them, what they might need help with, and what they would like to be different moving forward.

The process relies on building trust between the service and service user, to identify their needs and priorities, and identify how they might benefit from additional help and support.

It may involve some basic questions but mainly provides an opportunity for a person to tell us in their own words what they are experiencing. The screening and assessment will:

  • take into account the service user’s needs and preferences
  • be clearly explained from outset
  • make sure the support is based on individual needs and is culturally-appropriate
  • make sure the service user is treated with respect and dignity
  • help identify what outcomes are important to the service user

It will not:

  • delay the service user getting the help they need
  • probe deeply into details of their experience

Yes. We get consent to make sure that we can:

  • create a safe environment to talk about what could be sensitive and personal information
  • tell them about the choices are available to them
  • support them in whatever choices they make
  • respect their decisions

Yes. The services received, and information provided by the service user, are confidential unless:

1) they consent to information being shared
2) they and/or any child are likely to be seriously injured - this will usually be called ‘at high risk of serious harm’

Services which form part of the integrated model will always try to tell a service user when their information is being shared, unless it’s not safe for them and/or any children, or if the service is unable to contact them.

If the service does have to share information in this situation, they will only share relevant information, which will improve their and/or their child’s safety.

If the services do not have a service user’s consent to share their information, they will talk to a senior member of the team about the situation, and write on the service user’s file what has been shared, why, and who with.

A service user’s information is securely stored electronically, and is only accessed by those providing support, or where consent has been given.

A service user has the right to access their own case file on the shared integrated services model caseload management system. You can find out how to do this by asking your key worker or emailing

More information about confidentiality and information is available in the integrated services model information sharing agreement.

There’s no time limit on how long a service user can access the integrated model, but the support offered by individual services may vary depending on the service user’s needs. There is also no time limit on how many times they can access the service. Support will be based on need and given at a pace which suits the service user. They can re-access support at any stage.

Yes. Service users have the option of being seen by someone of the gender which they’re most comfortable with.

We want to make sure that all service users have the same access to services, regardless of their language and communication needs, so we’ll make appropriate arrangements for interpretation and translation at the point of service delivery.

This is a new model and feedback will help us to assess the quality of relationships we have with service users and stakeholders, and can be used to improve people’s experiences of our services. Feedback will be completed during case-to-case work and evaluations. We want to deliver our service in a way which gives opportunities for people to be involved in the development and improvement of services. We expect that this forum will review the feedback we get.

If you have feedback about the integrated model and want to send the feedback in writing, please email

We understand that sometimes, people may not be satisfied with the service they’ve had. Complaints are important for us to learn valuable lessons to improve our services, and fix any mistakes.

If you want to make a complaint about the integrated model, please follow the adult social care comments and complaints process.

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