Sample policy · Reg 9

Accessible Information and Communication Policy

Statutory anchor: Regulation 9 (person-centred care), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 10 (dignity and respect), Regulation 11 (need for consent) and Regulation 17 (good governance), and is informed by the Accessible Information Standard (NHS England DAPB1605) and the reasonable-adjustments duty in the Equality Act 2010. · primary source

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Verivius pack version v1.2, 2026-07-19

1. Who this accessible information policy is for

This sample policy is for CQC-regulated providers that need a practical accessible information and communication policy for service users, patients, relatives, representatives and advocates. It is relevant to adult social care, dental, GP, independent healthcare, diagnostic, ambulance, community and private clinic services.

This is the right starting point where a provider needs an accessible information policy, communication needs policy or reasonable adjustments process for CQC evidence, not just a generic equality statement. It covers how the service identifies, records, flags, shares and meets communication needs across assessment, consent, appointment information, complaints, safeguarding, referrals, handovers, privacy information and digital access.

For the wider person-centred care evidence trail, use the Regulation 9 person-centred care explainer and the article on Regulation 9 evidence. This policy should sit alongside the service's consent policy, equality and diversity policy, complaints policy, safeguarding policy, privacy notice, service user guide and records standards.

2. What the regulation says

The care and treatment of service users must be appropriate, meet their needs, and reflect their preferences. (Reg 9(1): the headline duty)

carrying out, collaboratively with the relevant person, an assessment of the needs and preferences for care and treatment of the service user (Reg 9(3)(a): collaborative assessment)

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/9. Where this policy and the regulation diverge, the regulation wins.

All providers and commissioners of NHS and publicly funded adult social care services must have regard to the Accessible Information Standard. This includes independent providers of NHS-funded services and private, voluntary or community providers of publicly funded adult social care. Other providers should use its six-step approach as good practice where relevant, alongside CQC Regulation 9, Regulation 10, Regulation 11, Regulation 17 and Equality Act duties.

3. Plain-English summary

Care and treatment must be appropriate, meet the service user's needs, and reflect their preferences. The regulation lists nine specific things you have to do to deliver person-centred care, including: assessment with the service user, designing care to meet their preferences, involving them and the people supporting them in decisions, providing information, making reasonable adjustments, and considering well-being when meeting nutritional and hydration needs.

For services in scope of the Accessible Information Standard, the operating sequence is to identify, record, flag, share, meet and review information and communication support needs. A diagnosis or impairment label is not enough. The record must tell staff what support the person needs and prompt them to provide it.

4. Purpose

The purpose of this policy is to make sure that people using [Service Name] receive information they can access, understand and use, and receive communication support where they need it.

Accessible communication is part of person-centred care, dignity, consent, safety, equality and good governance.

5. Policy warning

The service must not assume that a person understands information simply because it has been given to them.

Important information must not be provided only in a format the person cannot use, such as small print, unsupported English, inaccessible digital forms or verbal-only explanations where the person needs another format.

Failure to meet communication needs can affect consent, safety, complaints, safeguarding, medicines, appointments and treatment decisions.

6. Scope

This policy applies to:

6.1 Local arrangements before adoption

Before adoption, [Service Name] records and tests:

The local procedure must work across reception, booking, clinical or care delivery, complaints and emergency contact. Staff must be able to find the flag and arrange the adjustment without relying on one person's memory.

7. Principles

The service will:

8. Responsibilities

The provider is responsible for ensuring systems and resources support accessible communication.

The Registered Manager is responsible for implementing this policy and auditing compliance.

Managers and senior staff are responsible for making sure staff know how to identify and meet needs.

All staff are responsible for checking communication needs, using recorded adjustments and escalating gaps.

9. Operational workflow: identify, record, flag, share, meet and review

Staff follow this sequence whenever a need is disclosed, observed or recorded by another service:

  1. Identify: ask the person what information or communication support they need and how staff should provide it. Do not record only a diagnosis or impairment.
  2. Record: enter the specific need and required action clearly in the approved clinical and administrative records, using current standardised terminology or coding where the service is required to do so.
  3. Flag: make the need highly visible to authorised staff at the point of booking, contact, care or treatment, and make the flag prompt an action rather than merely display information.
  4. Share: include the minimum necessary information in existing referral, transfer, discharge or handover processes where there is a lawful reason to share it.
  5. Meet: provide the agreed format, communication professional, appointment adjustment, aid or other support, then check that the person can access and understand the information.
  6. Review: ask whether the recorded need and action remain accurate at planned review points and after a communication failure, change in condition, request from the person or service transition.
  7. Escalate and learn: if a need cannot be met before care or treatment, escalate to the person in charge, assess whether it is safe and lawful to proceed, record the decision and create an improvement action for any system gap.

The sections below set the controls for each stage.

9.1 Identifying needs

Staff must ask whether the person has any information or communication needs.

Needs may relate to:

The service must not rely only on visible disability. Staff should ask sensitively.

10. Recording needs

Communication and information needs must be recorded in a clear and standardised way.

The record should include:

The record must be visible to staff who need it.

11. Flagging needs

The service must have a way to flag communication needs so staff act on them.

Flags may be used for:

A flag must not disclose unnecessary sensitive information to people who do not need it.

12. Sharing needs

Where lawful and necessary, communication and information needs should be shared with other services involved in the person's care or treatment.

Sharing may be relevant for:

The service must share enough information to support safe communication, but not more than necessary.

13. Acting on needs

The service must take practical steps to meet recorded needs.

This may include:

Staff must not ignore recorded needs because meeting them is inconvenient.

14. Consent and capacity

Accessible communication is essential to valid consent.

Before obtaining consent, staff must make reasonable efforts to ensure the person can understand, retain, use and weigh relevant information and communicate their decision.

Where there is reason to doubt capacity, the Mental Capacity Act 2005 must be followed.

Failure to provide accessible information can invalidate the decision-making process.

15. Complaints and safeguarding

People must be able to raise concerns and complaints in ways they can access.

The service must provide accessible complaints information and communication support.

Where safeguarding concerns arise, staff must make sure the person's communication needs are considered when obtaining their views, explaining actions and sharing information.

16. Digital access

Digital systems must not exclude people who cannot use them.

Where forms, booking, privacy notices, complaints or care information are digital, the service must provide reasonable alternatives.

The service should check whether digital content is accessible, readable, mobile-friendly and compatible with assistive technology where relevant.

17. Interpreters and family support

The service should use professional interpreters where clinical, safeguarding, consent, complaint or confidentiality risk requires it.

Family members or friends may support communication where appropriate and where the person agrees, but they should not normally replace a professional interpreter for high-risk, sensitive or complex matters.

Children should not be used as interpreters for adult clinical or safeguarding matters except in an emergency where no alternative is available.

18. Review of communication needs

Communication needs must be reviewed:

19. Training

Staff must receive training appropriate to their role.

Training should include:

Training must be recorded.

20. Audit

The Registered Manager must audit accessible information and communication at least annually.

The audit should check:

Findings must be added to the action plan or risk register where required.

21. Records

The service must keep:

22. Policy review

This policy will be reviewed annually, or sooner following a CQC finding, complaint theme, communication-related incident, equality concern, digital-system change or change in relevant guidance.

23. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

24. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

For this policy specifically, seek advice where communication affects consent, capacity, serious treatment decisions, complaints, legal notices, refusal of care, discrimination risk or high-risk information sharing.

25. Document control

Version Date Author Changes
v1 2026-06-10 Verivius (sample) Conformed new cross-cutting draft to the Verivius policy standard.
v1.1 2026-07-10 Verivius (sample) Added intent-first guidance for providers looking for an accessible information, communication needs and reasonable-adjustments policy. No regulatory claims changed.
v1.2 2026-07-19 Verivius (sample) Updated the Accessible Information Standard reference to DAPB1605 and added local adoption decisions, the six-step operating workflow and auditable system controls.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the provider's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

A communication failure almost never announces itself. The person nods, the letter goes out in standard print, the form is signed, and nothing in the record shows that the information never actually landed. The harm surfaces later under someone else's heading: an appointment recorded as the person's own non-attendance, a treatment decision that would not survive scrutiny because they could not weigh what they were told, a safeguarding disclosure that never came because the only person able to interpret was the relative they were frightened of. That is why the flag has to reach reception and booking and not sit on the clinical record alone, and why the entry has to say what staff should do rather than name a diagnosis. Getting this trail right is not about producing evidence for an inspection, it is about removing the point at which a person quietly drops out of their own care.

  1. A recorded need actually prompts staff to act, not just displays a label on a screen. When the flag reaches booking, reception and clinical staff and triggers the adjustment, the person gets the format or support they need. The classic Accessible Information Standard failure is a need that is recorded and then never met.

    Strong evidence: The flag step of the workflow (section 9, step 3, where the flag prompts an action rather than merely displaying information) and the flagging controls (section 11).

    Weak evidence: The flag lives only on the clinical record, so booking still offers a standard slot and the letter still goes out in standard print. Ask a receptionist and an agency or bank member of staff to show you where the flag appears and what it tells them to do: if the answer is a coloured icon nobody can interpret, or "the manager knows", the flag is decoration rather than a prompt to act. The flag is our recommended mechanic rather than a legal requirement in its own right. What sits behind it is the Regulation 9 duty to meet the person's needs, and for NHS-funded services and publicly funded adult social care the flagging step also falls under the Accessible Information Standard.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  2. The record states the support the person needs, not just an impairment or diagnosis label. The entry tells the next member of staff what to do (format, interpreter, longer appointment), because a diagnosis on its own leaves them guessing when they meet the person for the first time.

    Strong evidence: The recording fields (section 10: need identified, preferred method, required format, support required) and step 2 of the workflow (section 9), against the principle in section 3 that a diagnosis or impairment label is not enough.

    Weak evidence: Entries that read "deaf", "learning disability" or "limited English" and stop there, with the required-format and support-required fields blank or filled with the diagnosis again. A member of staff meeting the person for the first time still cannot tell from the record whether to book a British Sign Language interpreter, send large print, or simply allow more time. Regulation 9(3)(a) requires the assessment of needs and preferences to be carried out with the person, and Regulation 17 requires the record of it to be accurate and complete. An impairment label on its own meets neither.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 9(3)(a) and reg 17(2)(c)

  3. Recorded needs are actually met before care, and understanding is checked, not ignored because meeting them is inconvenient. The agreed format, interpreter or adjustment is provided so the person can access and understand the information, not recorded and then left undone.

    Strong evidence: Step 5 of the workflow (section 9: provide the support, then check the person can access and understand) and the acting-on-needs controls (section 13), evidenced by accessible-format requests and interpreter bookings (section 21).

    Weak evidence: Accessible-format requests and interpreter bookings that thin out when the service is busy, and notes saying information was "given" or "discussed" with nothing to show the agreed format was used or that anyone checked what the person had taken in. Ask people to show you the letter they actually received: standard print landing with someone whose record specifies large print means the need was recorded and then never acted on, which is a Regulation 9 failure however good the recording was.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 9(1)(b)-(c) and reg 9(3)(b); Equality Act 2010 Sch 2 para 2(6)

  4. A need that could not be met before care is escalated and the decision recorded, not silently worked around. The person in charge decides whether it is safe and lawful to proceed, and a system gap becomes an improvement action instead of repeating unseen.

    Strong evidence: Step 7 of the workflow (section 9: escalate to the person in charge, assess whether it is safe and lawful to proceed, record the decision and create an improvement action).

    Weak evidence: The gap gets worked round and nobody writes it down: the interpreter does not arrive and the note simply says the appointment proceeded, or a relative translated because it was quicker. There is no record of who decided to continue, whether continuing was safe and lawful, and no improvement action naming the booking or supplier failure, so the audit and action plan show a clean sheet while the same failure repeats. The escalate-and-record step here is a Verivius default that gives Regulation 17 governance something to work with.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  5. Consent follows accessible information, not precedes it. Communication support is in place so the person can understand, retain, use and weigh the information, with the Mental Capacity Act 2005 followed where capacity is in doubt.

    Strong evidence: The consent and capacity section (section 14: failure to provide accessible information can invalidate the decision-making process) and the consent and capacity records (section 21).

    Weak evidence: Signed consent forms with no trace of what communication support was in place when the conversation happened, so nothing shows the person could understand, retain, use and weigh what they were told. Watch for consent obtained through a relative, consent taken before the interpreter arrived, or a note that capacity was doubted with no Mental Capacity Act 2005 assessment or best-interests record behind it.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Mental Capacity Act 2005 s.1(3) and s.3(2); Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 11(1) and (3)

  6. Professional interpreters are used for high-risk, clinical or safeguarding matters, not family members or children by default. That matters most for consent, safeguarding and confidentiality-sensitive conversations, where a mistranslation can change what the person agrees to or discloses.

    Strong evidence: The interpreters and family-support section (section 17: professional interpreters where clinical, safeguarding, consent, complaint or confidentiality risk requires it, and children not used as interpreters for adult clinical or safeguarding matters except in an emergency).

    Weak evidence: Interpreter bookings that cluster around routine review appointments and vanish from consent, safeguarding and complaint conversations, which are the ones where precision matters most. Records naming a son, daughter or "family interpreted" for a clinical discussion, or a child present as the interpreter for an adult's clinical or safeguarding matter with no note of the emergency that left no alternative. The rule that a professional interpreter is used for these conversations is the position this policy takes rather than a statutory test, but a consent or safeguarding conversation held through the person's relative is very hard to stand behind afterwards.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

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Last verified 20 July 2026

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Last reviewed 19 July 2026