5 February 2015
Inclusion Healthcare provides high quality primary health care service for homeless and for those vulnerably housed people in Leicester. It is a social enterprise which tackles social problems, improves communities and people’s life chances.
It is based at Charles Berry House and provides a city centre venue, close to public transport. It is purpose built with eight consultation rooms and a separate entrance for patients and staff. We found that patient focus was very strong and the practice had good links to many external agencies.
Inclusion Healthcare is run by a Chief Executive and three directors. The clinical team is led by a GP and consists of a Consultant Nurse, three female and one male part time GP’s, two practice nurses, a primary care plus (PCP) nurse, specialist alcohol worker and a health care worker. It is supported by an administrative team. A PCP nurse works with hostels, local hospitals and in the community. They provide additional support whilst homeless patients are in hospital and take an active role in ensuring that each patients discharge from hospital runs smoothly and helps reduce inappropriate attendance at the hospital’s emergency and urgent care departments
The practice is an accredited training practice with the East Midland Local Education and Training Board and at the time of our inspection had one GP registrars (fully qualified doctors who wish to become general practitioners).
The practice is located within the area covered by NHS Leicester City Clinical Commissioning Group (CCG). A CCG is an organisation that brings together local GPs and experienced health professionals to take on commissioning responsibilities for local health services.
Inclusion Healthcare recently came second and highly commended in the Health Service Journal (HSJ) awards for Compassionate Care. The HSJ gave the award for services that genuinely put patients at the heart of their care. It celebrated excellence in putting patients first, engaging patients and families in their care, listen to views and ensure people are treated with care and compassion.
We spoke with five patients including two members of the Patient Participation Group (PPG). The PPG is a group of patients who have volunteered to represent patients’ views and concerns and are seen as an effective way for patients and GP surgeries to work together to improve services and to promote health and improved quality of care.
We spoke with clinical, administrative staff and members of the management team. We also spoke with external partners. We looked at a range of information we hold about the service. We reviewed information from NHS Leicester City Clinical Commissioning Group (CCG), NHS England (NHSE), Public Health England (PHE), Healthwatch Leicestershire and NHS Choices.
Inclusion Healthcare has an Alternative Provider Medical Services Contract (APMS) contract for single homeless adults. They currently have around a 1000 patients but have a 50% to 70% turnover in a year. The APMS contract allows NHS England to contract with ‘any person’ under local commissioning arrangements.
We inspected the following location where regulated activities are provided:-
Charles Berry House, 45 East Bond St, Leicester.LE1 4SX
Clinics are provided at Charles Berry House from 8.30 to 11.30am and 2pm to 4.30pm. Nurse and GP clinics are held each day with the exception of Tuesday where there is no GP clinic.
We also visited the following branch location where regulated activities are provided :-
The Dawn Centre, Conduit St, Leicester.LE2 OJN
The Dawn Centre is run by Leicester City Council and is a project for homeless people providing support, advice and assistance. Inclusion Healthcare provides a drop-in nurse clinic from 8.30am-11.30am each morning Monday to Friday. There is a GP service on a Tuesday morning.
Inclusion Healthcare’s vision is to improve the health and wellbeing of homeless and other marginalised groups of people by the delivery of responsive and high quality health care service. They aim to be a national leader in the delivery of responsive, high quality healthcare with a demonstrable record of improving the health and wellbeing of the marginalised groups they serve.
Inclusion Healthcare has opted out of providing out-of-hours services (OOH) to their own patients. The OOH service is provided to Leicester City, Leicestershire and Rutland by Central Nottinghamshire Clinical Services. OOH is for when you need GP advice out of normal surgery hours, you can still phone your GP surgery but you will normally be directed to an out-of-hours service. This service is provided from 6.30pm to 8am on weekdays, and all day at weekends and on bank holidays.
5 February 2015
Letter from the Chief Inspector of General Practice
Inclusion Healthcare Social Enterprise CIC provides high quality primary health care services for homeless people. This included patients who were vulnerably housed, rough sleepers, squatters or sofa surfed in Leicester. It is based at Charles Berry House which was converted for purpose and provides an excellent city centre venue, close to public transport. It is purpose built with eight consultation rooms and separate entrances for patients and staff.
We carried out a comprehensive inspection on 6 November 2014.
We rated the practice as Outstanding. An effective, responsive and well-led service is provided that meets the needs of the population group it serves.
Our key findings were as follows:
- Patients were kept safe because there were arrangements in place for staff to report and learn from safety risks.
- There were systems in place to keep patients safe from the risk and spread of infection.
- The practice was responsive to the differing needs of its patient population.
- We saw that staff were able to identify and respond to changing risks to patients including deteriorating health and well-being or medical emergencies.
- Patients were treated with compassion, dignity and respect.
- To reduce ‘Do Not attend’ (DNA) rates a health care assistant attended appointments with the patient if requested to act as an advocate.
- The practice had a clear vision to improve the health of vulnerable and excluded groups.
- There was a culture of learning and development.
We saw areas of outstanding practice including:
- Learning from the diagnosis and treatment of the patient who had taken an overdose was shared with the whole team and other external agencies. Training was then provided to external agencies and clinical staff. Information was shared with commissioners and the drug and alcohol team as a safety alert.
- Staff gave examples of how they responded to patients experiencing a mental health crisis, including supporting them to access emergency care and treatment. The practice monitored repeat prescribing for people receiving medication for mental health needs.
- Referral rates to hospital for appointments are high as the patients are homeless people with complex physical and psychological needs. Do not attend (DNA) rates are high but the practice have started to put in place a system for a health care assistant who accompanied patients to appointments if they wished. The health care assistant reminds the patients of the appointment will accompany them and be with them in the consultation room if the patient requests it.
- The practice contributed to funeral costs and memorials for patients who were homeless. They have created a memory wall at the Anchor Centre. The Anchor Centre is a 'wet' day centre for street drinkers.
- The practice had a primary care plus (PCP) nurse. A PCP nurse works with hostels, local hospitals and in the community. They provide additional support whilst homeless patients are in hospital and take an active role in ensuring that each patient’s discharge from hospital runs smoothly and helps reduce inappropriate attendance at the hospitals’ emergency and urgent care departments. They support patients by accompanying them to hospital appointments.
- The practice used the Human and Environmental Risk Assessment (HERA) risk stratification tool, which helped doctors detect and prevent unwanted outcomes for patients. This helped to profile patients by allocating a risk score dependent on the complexity of their disease type or multiple comorbidities.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
5 February 2015
The practice is rated as outstanding for the population group of people with long term conditions.
We saw that staff were able to identify and respond to changing risks to patients including deteriorating health and well-being or medical emergencies. For patients with long term conditions there were emergency processes in place. For example, care of patients with diabetes who lived in the hostel at the Dawn Centre. The practice had clinics at the Dawn Centre which gave them the opportunity to monitor this group of patients. Diabetes is made worse by levels of alcohol abuse and mental health problems.
Referrals are made for patients with long term conditions who had a sudden deterioration in health. When needed, longer appointments and visits to hostel were available. All patients with long term conditions had a named GP and structured annual reviews to check their health and medication needs were being met. For those people with the most complex needs the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.
The practice had a lead nurse for long term conditions who had completed training, for example, in lung function testing. They received ongoing training from the local hospital and had developed external links with local specialist nurses.
5 February 2015
The practice are not rated for families, children and young people as they only had two children and four families registered on the day of inspection. The practice were able to see children and appointments were available outside of school hours and the premises was suitable for children and babies. Emergency processes were in place and referrals were made for children and pregnant women whose health deteriorated suddenly.
5 February 2015
The practice is rated as outstanding for the population group of working-age people (including those recently retired and students).
The practice used the Human and Environmental Risk Assessment (HERA) risk stratification tool, which helped doctors detect and prevent unwanted outcomes for patients. This helped to profile patients by allocating a risk score dependent on the complexity of their disease type or multiple comorbidities.
The practice had a primary care plus nurse who worked as the interface between primary and secondary care and other agencies such as social care. She provided a communication link for patients being admitted and discharged from hospital. This helped ensure a safe admission and discharge for the patient.
5 February 2015
The practice is rated as outstanding for the population group of people experiencing poor mental health.
Staff gave examples of how they responded to patients experiencing a mental health crisis, including supporting them to access emergency care and treatment. This was a system in place and the practice had a close working partnership with the mental health team who were available from Monday to Friday each week. Mental Health Crisis was managed in partnership with the Mental Health Crisis team. At weekends the out-of-hours (OOH) service had access to the records and the most at risk notified to OOH at the end of the day and at weekends. The practice monitored repeat prescribing for people receiving medication for mental health needs.
The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health including those with dementia. The practice had sign-posted patients experiencing poor mental health to various support groups and third sector organisations including MIND. MIND is a mental health charity in England and Wales offering information and advice to people with mental health problems.
The practice had a system in place to follow up on patients who had attended the accident and emergency department where there may have been mental health needs. Staff had received training on how to care for people with mental health needs and dementia.
5 February 2015
The practice is rated as outstanding for the population group of people whose circumstances may make them vulnerable.
Referral rates to hospital for appointments were above average compared to the local clinical commissioning group (CCG) but the patients were high demand, homeless people with complex physical and psychological problems.
Do not attend (DNA) rates were also above average compared to the local CCG but the practice had started to put in place a system for a health care assistant to attend appointments with the patient. They supported vulnerable patients to access information and services. The health care assistant reminded the patient of their appointment, would accompany them and be with them in the consultation room if the patient requested it.
The practice held a register of patients living in vulnerable circumstances including homeless people, refugees and those with learning disabilities. The practice had carried out annual health checks for people with learning disabilities and patients had received a follow-up. The practice offered longer appointments for people with learning disabilities.
The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people. The practice had sign-posted vulnerable patients to various support groups and third sector organisations. Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in and out of hours.
The consultant nurse and senior practice nurse went out with Leicester City Council Homeless Outreach team every six months to visit people who slept rough. They offered brief health assessments and supported people to register with the practice where appropriate.