Inclusion Healthcare Social Enterprise CIC

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

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

The service demonstrated a strong and proactive safety culture, with effective systems to protect patients and ensure safe care. Staff followed clear procedures for incident reporting and learning, supported by open and transparent leadership. Medicines were managed safely, with robust monitoring and prompt action to address any gaps, including flexible approaches for hard-to-reach patients.

Clinical care adhered to evidence-based guidance, and staff received appropriate training, supervision, and governance oversight. The environment and equipment were clean, safe, and well-maintained, with staff knowledgeable about safeguarding and risk management. Overall, the service showed a strong commitment to continuous improvement and patient safety.

This service scored 78 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to identify and embed good practice continually.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, incidents and learning was discussed and learnt from clinical issues. Staff felt there was an open culture and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The practice had robust systems and processes in place to ensure information was effectively shared across teams and agencies, enabling the delivery of safe, coordinated care. Collaborative work with other providers supported continuity of care, especially when patients transitioned between services.

There were systems in place for processing information relating to new patients. Where patients were moving to other areas, the practice would ensure information was transferred and, if needed, follow up with any additional support as the person moved to the new location. The service worked with other providers and services such as social services, charities and other healthcare providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

The practice worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. They had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They always shared concerns quickly and appropriately.

The practice worked closely with other organisations such as social services and charities to support patients in difficult circumstances, as the practice population were either homeless or seeking asylum, they prioritised safeguarding in each appointment. As a team, they would refer internally for mental health support and engage directly with secondary care to ensure patients were supported through their referrals. This included working closely with the local emergency department, which was often the first place patients presented to, to ensure they could be followed and care in the community was provided to reduce further attendances.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns, working in partnership with other organisations.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service operated from a building which had been adapted to provide clinical and non-clinical areas that provided essential facilities, including safe access for individuals with physical disabilities. The premises were clean and equipped with appropriate resources to support effective infection prevention and control.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken, and risks identified had been addressed. There was a business continuity plan in place, which was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There was a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff were managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection prevention and control lead, and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions were taken to mitigate risks.

The service ensured that medicines and treatments were safe, appropriate, and aligned with each person’s needs, capacity, and preferences. Patients were actively involved in planning their care, including when changes to treatment were necessary.

Clinical records reviewed during the inspection demonstrated that medicines were managed safely and in accordance with current best practice and relevant professional guidance. For patients prescribed medicines that required routine monitoring, there was clear evidence of appropriate oversight and regular safety checks. In cases where a small number of patients were overdue for monitoring, the provider took immediate action, and all outstanding checks were completed as part of the assessment process.

The practice conducted regular medication reviews to ensure that prescriptions remained appropriate to individual needs. Given the nature of the patient population, many of whom faced challenges in attending scheduled appointments, the practice had adopted a flexible and patient-centred approach. A policy was in place to make the most of each patient contact by conducting blood tests and medicine reviews opportunistically, rather than relying solely on scheduled recall systems. This ensured important monitoring was carried out in a timely and pragmatic way, improving safety while accommodating the realities of patients' circumstances.