Accessible Information and Communication Policy

1. 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.

The Accessible Information Standard applies directly to organisations providing publicly funded NHS care or adult social care. Other providers should use it as good practice where relevant, alongside CQC Regulation 9, Regulation 10, Regulation 11, Regulation 17 and Equality Act duties.

2. 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.

3. 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.

4. 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.

5. Scope

This policy applies to:

• initial assessment
• booking and reception
• care and treatment information
• consent discussions
• complaints
• safeguarding
• care plans
• appointment information
• letters, emails and text messages
• digital portals
• telephone and video contact
• referrals and handovers
• notices and signs
• service user guide
• privacy information
• emergency information
• discharge or transfer information

6. Principles

The service will:

• ask about communication and information needs
• record needs clearly
• flag needs so staff can see and act on them
• share needs lawfully where needed for care or treatment
• act to meet those needs
• review needs regularly
• make reasonable adjustments
• avoid discrimination
• support valid consent and involvement
• check understanding

7. 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.

8. Identifying needs

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

Needs may relate to:

• visual impairment
• hearing impairment
• sensory loss
• learning disability
• autism
• dementia
• cognitive impairment
• acquired brain injury
• mental health
• language
• literacy
• speech impairment
• use of British Sign Language
• use of Makaton or other communication systems
• need for easy-read information
• need for large print, audio or digital format
• need for interpreter or advocate
• need for support person

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

9. Recording needs

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

The record should include:

• need identified
• preferred communication method
• required format
• support required
• interpreter or communication professional needed
• whether family or advocate may support communication
• consent for sharing communication needs
• review date

The record must be visible to staff who need it.

10. Flagging needs

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

Flags may be used for:

• booking appointments
• reception contact
• clinical consultations
• care visits
• complaints
• safeguarding concerns
• referrals
• emergency contact
• letters or digital communication

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

11. 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:

• referral letters
• hospital transfer
• ambulance or patient transport
• safeguarding referral
• GP communication
• specialist appointment
• complaints handling
• discharge planning

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

12. Acting on needs

The service must take practical steps to meet recorded needs.

This may include:

• easy-read information
• large print
• audio
• braille
• translated material
• interpreter
• BSL interpreter
• communication aid
• longer appointment
• quiet waiting space
• written summary after conversation
• visual prompts
• support from advocate or representative
• accessible digital documents
• telephone alternative to digital forms
• face-to-face option where needed
• checking understanding

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

13. 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.

14. 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.

15. 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.

16. 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.

17. Review of communication needs

Communication needs must be reviewed:

• at planned review
• when the person's condition changes
• when staff identify misunderstanding
• after complaint or incident
• after missed appointment linked to communication
• after transfer or referral concern
• when the person or representative asks for a change

18. Training

Staff must receive training appropriate to their role.

Training should include:

• equality and reasonable adjustments
• communication needs
• Accessible Information Standard where applicable
• consent and understanding
• use of interpreters
• easy-read and accessible formats
• recording and flagging needs
• confidentiality
• safeguarding communication
• digital exclusion

Training must be recorded.

19. Audit

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

The audit should check:

• whether needs are asked about
• whether needs are recorded
• whether flags are used
• whether accessible formats are provided
• whether interpreters are arranged where needed
• complaints accessibility
• consent records
• missed communication incidents
• staff training
• action completion

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

20. Records

The service must keep:

• communication needs record
• accessible-format requests
• interpreter bookings
• consent and capacity records
• complaints accessibility records
• referrals showing shared communication needs
• training records
• audit records
• actions taken

21. 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.

22. 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.

• CQC Regulation 9: Person-centred care (https://www.legislation.gov.uk/uksi/2014/2936/regulation/9)
• CQC Regulation 10: Dignity and respect
• CQC Regulation 11: Need for consent
• CQC Regulation 17: Good governance
• Accessible Information Standard (NHS England DCB1605), where the service is in scope
• NHS England Accessible Information Standard implementation guidance
• Equality Act 2010 reasonable-adjustments duty (https://www.legislation.gov.uk/ukpga/2010/15)
• Equality and Human Rights Commission guidance
• CQC equality and human-rights guidance
• Mental Capacity Act 2005 (https://www.legislation.gov.uk/ukpga/2005/9)
• ICO guidance where communication involves personal data sharing

23. 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.

24. Document control

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