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Inclusion Healthcare Social Enterprise CIC Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 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 theAnchor Centre. TheAnchor 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

Inspection areas

Safe

Outstanding

Updated 5 February 2015

The practice is rated as outstanding for providing safe services. This practice was safer than other similar practices and was improving consistently. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. The practice used every opportunity to learn from internal and external incidents, to support improvement. Information about safety was highly valued and was used to promote learning and improvement. Risk management was comprehensive, well embedded and recognised as the responsibility of all staff. There were enough staff to keep people safe.

Effective

Outstanding

Updated 5 February 2015

The practice is rated as outstanding for effective. Our findings at inspection showed systems were in place to ensure that all clinicians were not only up-to-date with both NICE guidelines and other locally agreed guidelines but we also saw evidence that confirmed that these guidelines were influencing and improving practice and outcomes for their patients. The practice was using innovative and proactive methods to improve patient outcomes and it links with other local providers to share best practice. There was an excellent system for completing and learning from clinical audit cycles with learning being shared with the practice and external organisations.

Caring

Outstanding

Updated 5 February 2015

The practice is rated as outstanding for caring. Data showed patients rated the practice higher than others for almost all aspects of care. Feedback from patients about their care and treatment was consistently and strongly positive. We observed a patient centred culture and found strong evidence that staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieve this. We found many positive examples to demonstrate how people’s choices and preferences were valued and acted on. The practice regularly engaged with many services across Leicester, for example, community health care professionals, hostel and emergency accommodation, prison and young offenders institution. Views of external stakeholders were very positive and aligned with our findings.

Responsive

Outstanding

Updated 5 February 2015

The practice is rated as outstanding for responsive. We found the practice had initiated positive service improvements for their patients that were over and above their contractual obligations. The practice had implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from the Patient Participation Group (PPG). The practice had reviewed the needs of their local population and engaged with the NHS Local Area Team (LAT) and Clinical Commissioning Group (CCG) to secure service improvements where these had been identified.

Patients reported good access to the practice with face to face appointments always available on the day requested. The practice had good facilities and was well equipped to treat patients and meet their needs. There was an accessible complaints system with evidence demonstrating that the practice responded quickly to issues raised. There was evidence of shared learning from complaints with staff and other stakeholders.

Well-led

Outstanding

Updated 5 February 2015

The practice is rated as outstanding for well-led. The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff. High standards were promoted and owned by all practice staff with evidence of team working across all roles. Governance and performance management arrangements had been proactively reviewed and took account of current models of best practice. The practice carried out proactive succession planning. We found there was a high level of constructive staff engagement and a high level of staff satisfaction. The practice was very active within the locality and have excellent attendance at both locality and practice learning team meetings. The practice sought feedback from patients, which included using new technology, and had a very active patient participation group (PPG).

Checks on specific services

People with long term conditions

Outstanding

Updated 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.

Families, children and young people

Not sufficient evidence to rate

Updated 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.

Older people

Not sufficient evidence to rate

Updated 5 February 2015

We have not included the older people population group as the practice did not have any patients registered in this range.

Working age people (including those recently retired and students)

Outstanding

Updated 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.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 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.

People whose circumstances may make them vulnerable

Outstanding

Updated 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.