Inclusion Healthcare Social Enterprise CIC

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

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

The service had a clear, inclusive vision centred on equality, compassion, and person-centred care, supported by strong and effective leadership. Leaders demonstrated a deep understanding of their patients’ needs and a commitment to continuous improvement, collaboration, and innovation. A culture of openness, integrity, and accountability was evident, with staff feeling supported and actively involved in shaping the practice’s strategy and development. Robust governance systems ensured effective oversight of safety, training, and quality improvement, and the leadership team responded proactively to challenges such as workforce pressures and complex patient needs. Collaboration with external partners strengthened shared learning and community outcomes. Overall, the service’s strong, compassionate leadership enabled it to deliver high-quality care and maintain excellent patient satisfaction among a vulnerable population.

This service scored 82 (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 clear and well-embedded shared vision, strategy, and culture, underpinned by principles of transparency, equity, equality and human rights, diversity and inclusion, and meaningful engagement. This vision was informed by an exceptional understanding of the challenges faced by the local population, particularly those from marginalised and vulnerable communities.

Staff demonstrated a strong awareness of how care, treatment, and support were delivered in line with the practice’s values. The practice’s strategy, vision, and values were regularly reviewed and discussed at business meetings, ensuring alignment across all levels of the organisation. These values had been co-developed with staff input, and systems were in place to ensure that all team members worked in accordance with them.

Staff spoke with passion and commitment about supporting the health needs of homeless individuals and asylum seekers, and this dedication was evident throughout the practice. Staff told us of times they had supported patients in the winter with appropriate clothing, paying for a taxi to allow patients to access clinical care and donating Christmas toys for children. They were keen to support the patients in direct ways where possible, as well as signposting to local charities.

The management team maintained strong oversight of training and governance. Records reviewed during the inspection confirmed that staff were up to date with mandatory training requirements, and appropriate supervision and assurance processes were in place for non-medical prescribers.

Staff at all levels continued to contribute to the ongoing development of the practice’s vision and strategy, which remained under active review. The practice was also responsive to increasing demand for its services, particularly in relation to the growing number of asylum seekers in the area and was actively working with partner agencies to plan for and address future challenges.

The service was led by inclusive leaders at all levels who demonstrated a clear understanding of the context in which they delivered care, treatment, and support. Leaders consistently embodied the organisation’s culture and values, and were regarded as credible, knowledgeable, and experienced. They led with integrity, openness, and honesty.

Staff feedback regarding leadership accessibility was generally positive. During the inspection, staff reported feeling listened to and supported by their team leaders and peers. While some staff noted that the physical location of management offices, situated upstairs, could lead to a sense of working in relative isolation during shifts, they acknowledged that the building layout was designed to allow patients to be supported in the most appropriate and calming environments.

Despite this, staff described the leadership team as approachable and responsive to concerns. Leaders were seen as role models who upheld and demonstrated the practice’s core values in their daily work. Additionally, the leadership team actively collaborated with other local practices, social care providers, and secondary care services to support integrated care across the community.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff demonstrated an awareness of how to access the Freedom To Speak Up (FTSU) guardian. Staff said they were also able to raise issues with their team leads, GP partners or the managers of the practice as they chose.

The service placed a strong emphasis on valuing diversity within its workforce and was committed to fostering an inclusive and fair organisational culture. Efforts were made to improve equality and equity for all staff, with a focus on creating a supportive and respectful working environment.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures.

Managers held regular practice meetings, during which they discussed clinical concerns and emerging risks. We saw that managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

The service demonstrated a clear commitment to its duty to collaborate and work in partnership, ensuring that care and support services operated seamlessly for patients. The practice consistently shared information and learning with partner organisations and engaged in joint efforts to drive improvement. Leaders and staff worked closely with local authority teams, secondary care providers, social care services, and voluntary and charitable organisations to deliver coordinated, person-centred care.

This collaborative approach was evident in a range of initiatives, including joint outreach with the homeless team, participation in the local Drug and Alcohol Death Review Panel, and involvement in integrated palliative care planning for vulnerable patients. The practice also responded proactively to the increasing healthcare demands among asylum seekers by working with external agencies to ensure services remained accessible, appropriate, and inclusive.

These partnerships reflected the leadership team’s deep understanding of the specific needs of the homeless and asylum-seeking populations and their ongoing commitment to reducing health inequalities. The practice's strong culture of collaboration supported the delivery of joined-up care and contributed to improved outcomes for some of the most marginalised members of the community.

The service demonstrated a strong focus on continuous learning, innovation, and improvement across the organisation and within the wider local health system. There was a clear commitment to exploring creative and effective ways of delivering equitable care, ensuring consistent quality of experience, outcomes, and quality of life for all patients, particularly those from marginalised groups. The practice actively contributed to safe and effective clinical practice and engaged in wider research and service development initiatives.

The recent renewal of the service contract has enabled the leadership team to progress plans to improve the physical environment of the building—an area they had identified as requiring enhancement to better support both staff wellbeing and patient care. Looking ahead, the practice is ambitious about expanding its reach and impact, with plans to extend its model of care and specialist expertise in supporting homeless and asylum-seeking populations across the wider region of Leicestershire and Rutland.