Inclusion Healthcare Social Enterprise CIC

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

At our last assessment, we rated this key question as Outstanding. At this assessment, the rating remains Outstanding.

The service was exceptional at making sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

The service was highly responsive to the diverse and complex needs of its patients, including people experiencing homelessness, asylum seekers, and those with significant health challenges. Care was personalised and flexible, with accessible appointment options and same-day support where possible. A robust triage system ensured urgent needs, such as mental health crises, were prioritised. The practice demonstrated strong community engagement, working closely with partner organisations to deliver coordinated care, including outreach for homeless patients and home-based support for those with serious illness. Additional resources like multilingual tablets and emergency supplies further reduced barriers to access. Patient feedback highlighted high satisfaction and appreciation for the service’s inclusive, adaptable, and equitable approach to care.

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

This service scored 89 (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 made sure people were at the centre of their care and treatment choices, and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Results from the last GP patient survey showed 86% of patients stated that during their last GP appointment, they were involved as much as they wanted to be in decisions about their care and treatment. This was slightly below the national average of 90.9%.

Care plans reflected the physical, mental, emotional, and social needs of patients including those related to protected characteristics under the Equality Act. Our review of clinical records showed patients were supported to understand their condition and were involved in planning for their care needs. They were also involved in decisions about their care.

Patients who provided us feedback said they were given sufficient information to make decisions about their care and felt listened to during their appointments.

The service demonstrated an exceptional understanding of the diverse health and care needs of its patient population and local community. This insight enabled the delivery of joined-up, flexible care that supported patient choice and ensured continuity. The practice had a deep awareness of its patient demographic, including the significant hardships and trauma many individuals had experienced, both in their daily lives and in their journeys to the United Kingdom.

Care pathways were designed to address patients’ social, mental, and physical health needs from the very first appointment, with appropriate follow-up to ensure sustained support. This approach often involved a shared journey between staff and patients, with a strong emphasis on collaboration across services. Staff consistently took proactive steps to coordinate available resources and ensure that all elements of care were aligned in pursuit of the best possible health outcomes for each individual.

The practice team consistently demonstrated a commitment to addressing the social needs of their patients, going beyond clinical care to provide meaningful, practical support. Examples included distributing ‘Safe in the Sun’ packs, containing water and sunscreen, to homeless patients during the summer months, maintaining an emergency clothing bank for individuals without seasonally appropriate attire, and offering donated toys at Christmas for parents who would otherwise be unable to provide gifts for their children. These initiatives complemented the practice’s close collaboration with local charities and support services, helping to ensure sustained provision of care and assistance for those in need.

The practice made reasonable adjustments when people found it hard to access services. There were arrangements in place for people who needed translation services. The practice complied with the Accessible Information Standard.

We saw the practice worked in partnership with other services to meet the needs of its patient population. During the inspection, we saw many examples of positive outcomes for patients from the practice tailoring its services to meet the diverse needs of its community. There were established mechanisms for engaging with secondary care and local health care providers.

The service was exceptional at developing appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Information to promote the take-up of screening and immunisation programmes was available in a range of languages. The practice had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard. Patients were informed as to how to access their care records.

Each area of the practice had relevant leaflets and signs in multiple languages, and the practice would print off information in the appropriate language for patients when required.

The service supported people to share feedback and ideas, or raise complaints about their care, treatment and support. They always involved people in decisions about their care and told them what had changed as a result.

We saw that complaints were managed in line with the practice’s policy. Learning from complaints was evident and staff were able to identify changes made as a result of patient feedback, including complaints.

The service was exceptional in ensuring that patients could access the care, support, and treatment they needed promptly. While the practice offered both online and telephone access, it recognised that many patients preferred to attend in person to book appointments. Reception staff responded flexibly and supportively, often arranging same-day appointments where possible to maximise the benefit of each visit and ensure patients' needs were met efficiently and compassionately.

A member of the practice team participated in a weekly outreach walk alongside the county council’s homeless outreach team, engaging directly with individuals experiencing homelessness in the community. This initiative aimed to raise awareness of the services available at the practice and to maintain contact with patients already registered. It also provided an important opportunity to build trust, encourage individuals to access healthcare, and ensure that the care provided remained relevant, compassionate, and responsive to the realities of patients’ lives.

People could access the service to suit their needs, for example, online, in person and by telephone. Treatment rooms were available on the ground.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this. The practice had reviewed deaths caused by overdoses and increased awareness of a medicine called naloxone, which is used to reverse the effects of an opioid overdose. Some of the patients had access to these through drug services, and clinicians raised awareness of the signs and symptoms of an overdose and how to use naloxone to save someone's life.

Feedback provided by people using the service, both to the provider as well as to CQC, was positive. Staff treated people equally and without discrimination. Leaders proactively sought ways to address any barriers to improving people’s experience and worked with local organisations, including within the voluntary sector, to address any local health inequalities. For example, when a patient was allocated a property but didn’t have any furniture, the practice supported them to access support to get the basics for themselves and their child.

Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes. Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have access to the internet.

People were given exceptional support to plan for important life changes, so they could make informed decisions about their future, including at the end of their life.

A member of staff attended the local Drug and Alcohol Death Review Panel and shared key outcomes from these meetings with the wider practice team. This learning was used to inform and adjust care delivery, ensuring there was ongoing awareness of the risks faced by the patient population. It also supported a proactive approach to safeguarding and tailoring interventions for those most at risk.

The practice actively supported homeless patients with a new diagnosis of cancer in accessing social support to facilitate the provision of palliative care at home. This involved close collaboration with social services and NHS teams, including district nurses, to ensure appropriate care was available in the patient’s new home environment when required. Often, this process included transferring the patient’s care to a local practice, with the team working diligently to maintain continuity and coordination during the transition to the new surgery.

Our records review showed people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. This information was shared with other services when necessary.