Integrated Crisis Response Service

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to outstanding. This meant people’s outcomes were consistently better than expected compared to similar services. People’s feedback described it as exceptional and distinctive.

This service scored 96 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them.

People spoke positively of the assessment process which began whilst in hospital for some. A family member told us, “My [relative] fell at home and was blue lighted to hospital. The hospital did an assessment and referred them to ICRS.”

All those we spoke with reflected upon the comprehensive assessments of their needs, and of their involvement in the process. A person told us, “ICRS completed a detailed assessment, which I was fully involved in. They treated me like a person not a burden. They took time to listen to me.”

Staff invested significantly in involving people, enabling to them to make changes to the support provided in response to people’s wishes. A family member told us, “We decided to have them once a day, they offered 3 times but once was enough.”

The assessment process was comprehensive and considered protected characteristics as defined by the Equality Act. All aspects of people’s needs were assessed, including general health, communication needs, age, race, religion and ethnicity. External factors were also included. For example, the role of family and friends in their lives, whether the person lived alone, and considered their housing and accommodation.

People’s assessments included a Care Act Assessment (an assessment undertaken by local authorities to identify a person’s support needs). Ongoing health and social care needs were identified and comprehensively discussed and documented within the assessment. ICRS staff referred people to the relevant services based on the outcome of the assessment, which included health and social care services and agencies. For example, referrals to a physiotherapist for mobility concerns, referrals to alcohol and drug support services, or referrals to housing and property management. A member of staff told us “ICRS Officers, undertake a Care Act Assessment and determine if ongoing care, such as a care agency is required, or potentially we can refer to the Reablement Provider Service where it has been identified a person may benefit from a period of rehabilitation.”

A key social care partner told us, “Daily multi-disciplinary team meetings, along with ICRS being co-located with therapy and nursing services, means daily referrals are made seven days a week in response to people’s assessed needs. ICRS works closely with other teams, making referrals to ensure the smooth handover to longer term social work teams, including reablement, community nursing and therapy, mental health teams and GP’s as and when needed.”

A key health care partner told us, “The service provides a 2-hour response, completing an initial holistic assessment and implementing immediate interventions to stabilise risk and support people to remain safely at home wherever possible. Whilst ICRS typically delivers short-term support (up to 72 hours) to stabilise a crisis, there is a strong focus on ensuring that any ongoing health or social needs are identified early, and that onward support is in place prior to discharge from the service.”

The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

People and family members were fully involved in decisions relating to their care and treatment, and on and ongoing basis, which included continued support and care decisions identified through the Care Act Assessment.

People and family members were fully informed of the role and remit of ICRS. A family member told us, “ICRS staff explained the emergency team would come out 3 times a day and told me they would come for 72 hours.”

Assessments of people’s needs included information relating to people’s dietary requirements, with consideration to culture, beliefs and health needs, as well as details as to arrangements for grocery shopping. In the event people were discharged from hospital, and their food stores at home were insufficient or had become unsafe to eat, due to being out of date, ICRS were able to provide the basics from the store cupboard in the ICRS office. For example, canned goods, dehydrated foods, tea and coffee.

Information regarding people’s dietary needs were documented. A member of staff told us, “Anything not considered typical, would be included on their notes. For example, if they required Halah, Kosher or fortified diets. We bring food packages for people without food.” Another member of staff said, “People’s records may include if a SALT (Speech and Language Therapy) assessment has been completed whilst they were in hospital, and the persons diet has been modified as they have been assessed as being at risk of choking.”

The provider used recognised tools in line with legislation and current evidence based good practice and standards. ICRS would refer people to their G.P. or a speech and language therapist if they identified concerns related to people’s nutrition and hydration, or where they identified people were at risk of choking.

The provider always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.

People benefited from robust systems and processes where information was shared by everyone involved in their care, with key health and social partners and agencies, working collaboratively to achieve effective care for people.

Health care partners worked collaboratively and alongside the Integrated Crisis Response Service. A health care partner told us, “ICRS is a key partner during MADE (Multi-Agency Discharge Events). During these events the emergency department patient cohort awaiting an acute bed is reviewed. ICRS staff are based on site and work proactively alongside discharge teams to support patient flow. While reviewing patients, the teams share relevant community background information to inform and strengthen discharge planning. They also actively identify opportunity to facilitate discharge directly from ED (emergency department) where appropriate, helping to reduce the risk of physical and mental deconditioning associated with prolonged stays in hospital.”

A multi-agency approach of key partner agencies, including community nursing therapy, care technology, mental health services, social workers, housing and care technology meant all services, facilitated by ICRS, worked collaboratively. This meant people received co-ordinated and timely care as they did not have to liaise with numerous agencies to secure the support and help, they required.

A key social care partner told us, “We have regular conversations with ICRS staff and managers about people who have been identified in need of support so that where ICRS support is required, this can be implemented quickly. Conversely, ICRS feedback to us about their interventions to inform our assessments of someone’s longer term needs where we are working jointly with them.”

ICRS ‘huddles’ were regularly held throughout the week involving the manager, and senior staff, including ICRS staff who undertook Care Act Assessments to discuss those people who had complex needs, to share ideas and identify and agree a way forward as to how best the service could support the person.

The provider always supported people to manage their health and wellbeing to fully maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

People and family members spoke of the positive impact the service had on their health and well-being. A person told us, “The ICRS team made a big difference to me psychologically and helped me feel stronger and more independent.”

People benefited from the core purpose of the service, which was to provide crisis intervention, by supporting people to stay at home, avoiding hospital admission, and enabling people to return home from hospital without the need for admission or a lengthy stay. This was facilitated through the provision of immediate and short-term care and support. The ability of ICRS staff to undertake Care Act Assessments, meant within a short period of time, they could expediate referrals to other services or agencies.

A key component of the service was its 24 hours a day 7 day a week service. Staffs’ ability to respond to people who had fallen at home, significantly reduced the period of time they spent on the floor, known as a ‘long lie. This had a direct and positive impact by reducing both the physical and psychological effects, and the need for admission to hospital, and the associated impact of being in hospital on a person. In 2025, 90% of people who were referred to the service due to a fall required no further support, whilst 4% were independent following short-term support, with 4% being admitted to hospital.

A key health care partner told us, “ICRS staff consistently demonstrate strong risk recognition, professional curiosity and timely escalation to prevent deterioration in people’s physical, mental health and well-being. As a health care partner, we have engaged the service on a number of complex cases where risks were unclear or evolving, in these situations, ICRS have completed prompt assessments, clearly articulated identified risk, and implemented immediate actions to stabilise individuals while wider support was coordinated.”

The provider monitored all people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

People were equivocal in their praise of the service and its impact on them. A family member told us, “ICRS help made such a difference to our lives. I was exhausted and now I have more time with my [child]. I want to say a big ‘thank you’ to the team.”

People’s expectations of the service were discussed with them, enabling the staff to provide or request the appropriate support through referrals to other services and agencies. Positive outcomes for people due to the involvement of the Integrated Crisis Response Service could be measured in numerous ways. For example, people accepting a referral be made to bespoke services, for drug and alcohol support services, or by staff liaising with housing services to provide support to facilitate improvements to their living environment.

People and family member’s views about the Integrated Crisis Response Service were sought, and records were maintained of the compliments received, evidencing people’s expectations of the service were met, and often exceeded. An example of a person’s compliment stated ‘I felt helpless at the beginning and slowly felt more independent. Thanks so much again.”

The positive impact on people as to the effectiveness of the ICRS was evidenced through the providers data. In 2025 there were 6,100 referrals to ICRS, of which 79% of people required no further support, 7.4% required ongoing care, 4.7% were referred to the reablement service and 3% of people remained in hospital.

The collaborative approach between the ICRS, health and social care professionals, and key stakeholder meant outcomes were monitored, both at an individual level but also within the wider context of the health and social care system. A key health care partner told us, “ICRS demonstrates a proactive and solutions-focused approach, using real time insight to highlight emerging pressures, risk and population needs. The team provide consistent outcome data which support informed decision making and helps ensures services remain aligned to prevention, crisis stabilisation and support people to remain safely at home”.

The provider always carefully explained to people what their rights around consent were, made sure they fully understood them and always fully respected these when delivering person-centred care and treatment.

People were fully involved in all decisions relating to their care and support. A person told us, “The carers were brilliant. They knew what they were doing, they always asked consent before doing anything, and I’m really involved in my care.”

Assessments of needs and Care Act Assessments considered people’s capacity to make informed decisions. ICRS staff were meticulous in recording people’s involvement in all decisions, including their decision not to engage with the service or other agencies. People’s decisions were always recorded, which included where it was being suggested a referral to other services or agencies may be of benefit to them. People’s decisions around referrals were documented, including where they had asked ICRS to speak with a named family member. Family members were contacted at the request of the person, and the outcome of the conversation recorded, along with the action taken. For example, a referral being made to an agency or service, where consent had been given.

A key health care partner told us, “Assessments are person-centred, with clear consideration given to capacity, consent and best interest decision-making, ensuring individuals and families remain involved in decisions about their care.”

The provider understood their responsibilities in relation to the Mental Capacity Act 2005 (MCA). The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires, that, as far as possible, people make their own decisions and are helped to do so when needed. Where people lack mental capacity to make particular decisions, any made on their behalf must be in their best interests, and as least restrictive as possible. Any information relating to Court of Protection would be recorded on systems which were accessible to ICRS staff.

Information about the service, including contact details was available in a number of languages and formats to support people in making informed decisions, which included, but was not limited to, Gujarati and Gujarati large print, Hindi, Somali and Polish.

Staff had undertaken training on the MCA and were aware all care interactions required the consent of the person. A member of staff told us, “We assume everyone has capacity, we check that they understand the information given. We ensure consent, understanding and retaining of information. We check with family how they wish to be involved, and with the person for their consent as to how much information they want to share with others, including family members.”