Inclusion Healthcare Social Enterprise CIC

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

At our last assessment, we rated this key question as outstanding. At this assessment, the rating has changed to Good.

The service provided effective, evidence-based, and well-coordinated care that met the complex needs of its patient population. Care was delivered in line with national guidance, and staff demonstrated strong clinical knowledge, particularly for patients with complex health conditions. Clinical records showed that treatment was safe and appropriate, supported by robust systems for monitoring medicines, reviewing test results, and ensuring timely follow-up.

The practice adopted flexible approaches to reach harder-to-engage groups, such as homeless patients, ensuring continuity and safety of care. Staff were kept up to date through regular training and oversight, and the service fostered a culture of continuous learning and improvement, contributing actively to local health initiatives and review panels.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service ensured that people’s care and treatment were effective by assessing and reviewing their health, care, wellbeing, and communication needs with them.

Feedback from people using the practice was positive. In the GP patient survey, 92% of patients said their needs were met during their last appointment.

People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. The reception staff were aware of the local community's needs. Reception staff utilised digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or the presence of a translator.

Staff checked people’s health, care, and well-being needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to mental health staff in the practice who would support patients with regular consultations and referrals to charities and organisations to support their mental and social health.

The service demonstrated a proactive, consistent, and positive safety culture, underpinned by openness, transparency, and a clear commitment to learning. Robust processes were in place for reporting incidents, near misses, and safety events, and these were followed consistently by all staff. Leadership actively listened to safety concerns, ensured thorough investigations were undertaken, and maintained a transparent approach to reporting and learning over time.

Care and treatment were planned and delivered collaboratively with patients, taking into account what mattered most to them. This was done in accordance with relevant legislation, clinical standards, and evidence-based best practice. During the inspection, a review of the clinical system confirmed that care was being delivered in line with current clinical guidance. There were effective systems in place for managing clinical correspondence and blood test results, ensuring timely interventions and continuity of care. We found patients were correctly coded and reviewed when they had long-term conditions such as diabetes and high blood pressure.

A clinical system search demonstrated that patients, prescribed medicines requiring routine blood monitoring, were being reviewed and managed in line with national guidelines. Systems were also in place to ensure that all staff remained up to date with evidence-based guidance and relevant legislation. Clinical records reviewed during the inspection reflected consistent application of current best practice across the service.

The service 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.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The practice had found that there was a high rate of patients who did not attend secondary care appointments. To reduce this, the practice team worked closely with the hospital booking office to ensure the appointments were communicated in a relevant way, for example, ensuring text messages closer to the appointment and telephone calls rather than letters to homeless patients, or in relevant languages to those asylum seekers whose first language was not English. This had reduced the ‘did not attend’ (DNA) rate for the practice patients by 9 percent.

The practice hosted occasional breakfast meetings for partners working with the homeless population in Leicester to tie together the approaches and ensure appropriate support was available and find gaps which could be filled to improve the health of the patients.

A Homeless Engagement Nurse was in place to review patients who frequently attended the Accident Emergency (AE) department instead of accessing care through the practice. These patients were proactively engaged to identify areas where additional support could be provided, to reduce AE attendances and improve health outcomes within the community. The nurse also held regular meetings with the hospital team to coordinate care, ensuring a more joined-up approach to meeting patients’ needs.

The practice recognised an increased need for mental health support among both homeless patients and those seeking asylum. In response, staff received additional training and developed a deeper understanding of the support services available. This empowered them to make direct referrals to appropriate services or to the in-house mental health team, ensuring timely follow-up. As a result, we found patients’ needs were addressed both clinically and holistically. The GP Patient Survey showed 88% of patients felt the professional they saw considered their mental health during the last appointment, this was against a national average of 74%.

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

Staff collaborated with local health teams to deliver Measles, Mumps, and Rubella (MMR) vaccinations at outreach locations regularly attended by homeless patients, integrating care into their routine environments rather than relying on practice-based appointments.

Staff focused on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking.

The service 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.

The practice maintained two separate datasets for its patient populations. One dataset focused on homeless patients, whose cervical screening uptake was notably lower, averaging around 46%—significantly below the national target of 80%. In contrast, data for patients who were in the process of seeking asylum showed a much higher engagement, with an average of 97% of eligible individuals having received cervical screening. The practice continued to engage with patients to increase this uptake; however, many patients would go on to register elsewhere once allocated longer-term accommodation, so they were only with the practice for a short period.

From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.