Accessible Information Standard (AIS) Policy and Procedure

Care Management – Care Practice

Review Sheet
Last Reviewed                                              Last Amended                                     Next Planned Review in 12 months, or 07 Mar ’24                                                      07 Mar ’24                                            sooner as required.
Business impact	Minimal action required circulate information amongst relevant parties. LOW IMPACT
Reason for this review	Scheduled review
Were changes made?	Yes
Summary:	This policy has been reviewed and remains appropriate. It supports staff to understand and implement the principles of The NHS Accessible Information Standard. Underpinning Knowledge and Further Reading Links have been reviewed and updated where applicable.
Relevant legislation:	•   Public Sector Bodies (Websites and Mobile Applications) (No. 2) Accessibility Regulations 2018 •   The Care Act 2014 •   Equality Act 2010 •   The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 •   Mental Capacity Act 2005 •   Access to Health Records Act 1990 •   Data Protection Act 2018 •   UK GDPR
Underpinning knowledge – What have we used to ensure that the policy is current:	•   Author: Information Commissioner’s Office, (2024), UK GDPR guidance and resources. [Online] Available from: https://ico.org.uk/for-organisations/guide-to-data- protection/guide-to-the-general-data-protection-regulation-gdpr/ [Accessed: 7/3/2024] •   Author: GOV.UK, (2023), Understanding accessibility requirements for public sector bodies. [Online] Available from: https://www.gov.uk/guidance/accessibility-requirements- for-public-sector-websites-and-apps [Accessed: 7/3/2024] •   Author: CQC, (2022), Meeting the Accessible Information Standard. [Online] Available from: https://www.cqc.org.uk/guidance-providers/meeting-accessible-information- standard [Accessed: 7/3/2024] •   Author: NHS England, (2017), Accessible Information Standard Implementation Guidance. [Online] Available from: https://www.england.nhs.uk/publication/accessible- information-standard-implementation-guidance/ [Accessed: 7/3/2024] •   Author: GOV UK, (2018), The Public Sector Bodies (Websites and Mobile Applications) Accessibility Regulations 2018. [Online] Available from: https://www.legislation.gov.uk/uksi/2018/852/contents/made [Accessed: 7/3/2024] •   Author: NHS England, (2017), Accessible Information Standard. [Online] Available from: https://www.england.nhs.uk/ourwork/accessibleinfo/ [Accessed: 7/3/2024]
Suggested action:	•   Encourage sharing the policy through the use of the QCS App
Equality Impact Assessment:	QCS have undertaken an equality analysis during the review of this policy. This statement is a written record that demonstrates that we have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by equality law.

 

 

 

• To make sure that Service Users (and those important to them) who have a disability, impairment or sensory loss, get information that they can access, understand and receive any communication support that they need from Mariama Care T/A Kangaroo
• To support Mariama Care T/A Kangaroo Healthcare in meeting the following Key Lines of Enquiry/Quality Statements (New):

(New)

Key Question                        Key Lines of Enquiry                                                           Quality Statements

 

CARING	C2: How does the service support people to express their views and be actively involved in making decisions about their care, support and treatment as far as possible?	QSC2: Treating people as individuals
EFFECTIVE	E4: How well do staff, teams and services within and across organisations work together to deliver effective care, support and treatment?	QSE3: How staff, teams & services work together
RESPONSIVE	R1: How do people receive personalised care that is responsive to their needs?	QSR1: Person- centred care
SAFE	S1: How do systems, processes and practices keep people safe and safeguarded from abuse?	QSS3: Safeguarding
WELL-LED	W4: How does the service continuously learn, improve, innovate and ensure sustainability?	QSW7: Learning, improvement and innovation
RESPONSIVE	No equivalent KLOE	QSR3: Providing information
SAFE	No equivalent KLOE	QSS2: Safe systems, pathways and transitions

 

• To meet the legal requirements of the regulated activities that Mariama Care T/A Kangaroo Healthcare is registered to provide:
  • Public Sector Bodies (Websites and Mobile Applications) (No. 2) Accessibility Regulations 2018
  • The Care Act 2014
  • Equality Act 2010
  • The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
  • Mental Capacity Act 2005
  • Access to Health Records Act 1990
  • Data Protection Act 2018
  • UK GDPR

 

 

 

• The following roles may be affected by this policy:
  • All staff
• The following Service Users may be affected by this policy:
  • Service Users
  • Family
  • Visitors
• The following stakeholders may be affected by this policy:
  • Family
  • Advocates
  • Representatives
  • Commissioners
  • External health professionals
  • Local Authority
  • NHS

• To ensure that Mariama Care T/A Kangaroo Healthcare complies with the NHS Accessible Information Standard, and that staff at Mariama Care T/A Kangaroo Healthcare consider how they will apply

the standard in a clear, consistent, transparent and fair way.

• For Mariama Care T/A Kangaroo Healthcare to have a clear, consistent, transparent and fair approach to the provision of accessible, inclusive information and communication support to

 

 

 

• All staff at Mariama Care T/A Kangaroo Healthcare have a responsibility to make information accessible and
• Mariama Care T/A Kangaroo Healthcare will comply fully with the NHS England Accessible Information Standard and will perform the following 5 steps:
  • Ask people if they have any information or communication needs, and find out how to meet their needs
  • Record those needs in a set way
  • Highlight in a Service User’s file so it is clear that they have information or communication needs, and clearly explain how these will be met
  • Share information about a person’s needs with other NHS and adult social care providers when there is consent or permission to do so
  • Act to make sure that people get information in an accessible way and receive communication support if they need it
• Staff will have a working knowledge of the NHS England Accessible Information Standard, and Mariama Care T/A Kangaroo Healthcare will be able to demonstrate compliance through audit and quality assurance processes.
• In line with UK GDPR, data protection legislation, Mariama Care T/A Kangaroo Healthcare will enable Service Users to access their records when requested, and this includes the right to review and amend their documented communication
• Where Service Users are unable to provide consent in relation to their wishes with sharing of information, all decisions regarding this area will be made in line with the Mental Capacity Act 2005 and best interests
• Mariama Care T/A Kangaroo Healthcare will also comply with the Accessibility Regulations that came into force for public sector bodies in 2018 and require reasonable adjustments to be made to websites and mobile apps for those with disabilities to ensure that they remain

The regulations require a service’s website to comply with WCAG2.1 AA by:

• Ensuring that the website is ‘perceivable, operable, understandable and robust’
• Having an accessibility statement available on the website

Although some services may be exempt from the regulations (full government guidance can be referred to here), Mariama Care T/A Kangaroo Healthcare recognises it has an obligation to ensure that reasonable a djustments are in place for disabled people.

 

 

 

5.1  Steps to the Accessible Standard

There are five basic steps which make up the Accessible Information Standard:

1. Ask: Identify/find out if a Service User has any communication or information needs relating to a disability or sensory loss, and if so, what they
2. Record: Record those needs in a clear, unambiguous and standardised way in electronic and/or paper- based records/administrative systems or
3. Alert / Flag / Highlight: Ensure that the recorded needs are highly visible whenever the Service User’s record is accessed, and prompt for
4. Share: Include information about the Service User’s information/communication needs as part of existing data sharing processes (and in line with existing information governance frameworks).
5. Act: Take steps to ensure that Service Users receive information which they can access and understand, and receive communication support if they need

5.2  Step 1 – Ask

At the earliest opportunity, e.g. when an enquiry for a Care service is raised, receiving staff must establish any communication needs or wishes in a timely manner.

Pre-assessment

Before commencing any Care, an assessment will be completed that identifies the communication needs and wishes of the Service User. This information gathering will include identifying how the Service User manages this and what support they will need from staff in order to enable effective communication.

Before commencing Care, Hannah Addo must determine that Mariama Care T/A Kangaroo Healthcare can meet the communication needs of the Service User. Staff must avoid making any assumptions about Service Users’ communication needs, and must take care to record people’s communication needs specifically and separately from any recording of disability or other protected characteristic status.

5.3  Ongoing Assessment

As part of the Care Plan cycle, assessments will be reviewed in accordance with locally agreed timescales or as a Service User’s condition changes. As part of this, staff will revisit and identify any new communication needs and support accordingly.

Hannah Addo will consider how to promote enabling all individuals accessing Mariama Care T/A Kangaroo Healthcare to express their communication needs and wishes.

There are a range of resources (e.g. posters and leaflets) that can be accessed via NHS England that can help to raise awareness that Mariama Care T/A Kangaroo Healthcare will accommodate different communication preferences (refer to the Further Reading section of this policy).

5.4  Step 2 – Record

Recording of communication needs and preferences will be highly visible and clear on paper formats

(i.e. jargon free, in a simple language). Where electronic systems are used, coding must be in accordance with the defined terminology and assurance will be gained that persons receiving this shared information understand it.

5.5  Step 3 – Alert/ Flag/ Highlight

Staff at Mariama Care T/A Kangaroo Healthcare must have systems in place to ensure that records (electronic or paper-based) clearly flag that the Service User has a recorded communication need – they will be highly visible and prompt staff to take action.

Where facilities are in place for automatically generated correspondence, alerts will pick up the requirement for alternative formats. Staff responsible for overseeing standard print letter releases to Service Users must have systems in place to not send these where it would be inappropriate or

inaccessible for that person. Mariama Care T/A Kangaroo Healthcare will investigate and learn from any incidents of this nature.

5.6  Step 4 – Share

Consent will be gained from the Service User who has identified specific communication preferences and needs in relation to sharing this information. Any limitations to this must also be documented and clarity provided as to what information can be shared, with whom, in what circumstances, and for what purposes. Where consent cannot be obtained due to reduced capacity, staff should refer to the Mental Capacity Act (MCA) 2005 Policy and Procedure of Mariama Care T/A Kangaroo Healthcare and best interest decisions made in line with the code of practice.

Existing internal and external communication systems such as the referral, transfer of Care and handover processes will include reference to communication support required for Service Users.

 

 

5.7  Step 5 – Act

Staff must be aware of how to adapt their own communication styles to meet the needs of a Service User, and they must also be competent with the use of any techniques or aids used by Service Users.

It is acknowledged that it may take time to establish communication needs from Service Users that choose to not disclose this information, and they must be encouraged to discuss their needs with staff.

Service Users who use limited or no English, and those who use British Sign Language (BSL) or the deaf- blind manual alphabet, will have access to a professional interpreter. Staff will support the Service User to access this and will work with any advice and support offered by the interpreter.

Where staff are required to support Service Users to source an interpreter or communication professional, this must be based on the following considerations:

• Qualifications
• DBS clearance
• Professional code of conduct
• Experience
• Preference of the Service User (e.g. in relation to gender)
• Specialist skills needed

Any concerns in relation to the suitability or practice of the interpreter will be discussed with Hannah Addo.

5.8  Environment

Although the Accessible Information Standard does not include environmental or facilities matters, some aspects apply to Service Users with a disability, impairment or sensory loss, in order to facilitate communication.

Staff must always consider whether some rooms are ‘better’ than others for people with communication needs, e.g. less clutter, improved lighting, soundproof. As part of the Care Plan process, the environment must be considered and appropriate locations detailed in the Care Plan where specific rooms might provide better support to facilitate communication.

Staff will consider lighting, in particular where lip reading is vital for the Service User.

Hannah Addo will accommodate communication aids that support individuals with communication, such as loop systems, in agreement and review with Mariama Care/T/A Kangaroo Healthcare Ltd.

5.9  Conversion of Format

Hannah Addo must consider in advance how to facilitate the conversion of key documents, policies and procedures in a timely manner. Hannah Addo will identify which communication formats can be used or produced within Mariama Care T/A Kangaroo Healthcare, for example, email and text message (for people who are deaf as an alternative to telephone, and for people who are blind as an alternative to printed information), and large print.

Staff should also refer to the Recite Me tool within QCS Compliance Centre, which will support with the conversion of policies and resources into different languages, large print and audio amongst other available functions.

A local suite of support services and points of contact will be made available in readiness for accessing specific communication requirements that cannot be met within Mariama Care T/A Kangaroo Healthcare. Hannah Addo will consider how needs can be met by the use of remote, virtual, digital and telecommunications solutions, as well as paper format.

• Staff can refer to the Supporting Communication and Sensory Needs Policy and Procedure

of Mariama Care T/A Kangaroo Healthcare for practical support and procedures that can extend to any person accessing Mariama Care T/A Kangaroo Healthcare.

Time should be factored into accommodating communication needs, as some Service Users may need longer periods of time to process information than others.

5.11  Training and Education

New staff joining Mariama Care T/A Kangaroo Healthcare will receive an induction that includes communication. For new Care Workers, they will also be required to complete the Care Certificate which includes standards around communication.

Ongoing, staff will be encouraged to develop their learning further. This will be identified through supervisions and appraisals, and by training needs analysis.

5.12  Audit and Review

Hannah Addo will ensure that processes are in place to make sure that information recorded is current and accurate.

 

 

Record keeping audit processes will include a review of the communication preferences of Service Users. Overarching quality assurance checks of Mariama Care T/A Kangaroo Healthcare will identify meeting the needs of any Service User accessing Mariama Care T/A Kangaroo Healthcare. Any findings of discrepancy will be immediately acted upon and reflected upon to ensure the risk of reoccurrence is reduced.

Service Users will be supported to provide feedback about their experiences, with information received by Mariama Care T/A Kangaroo Healthcare in the most appropriate forum. Information received will be acted upon as part of the continuous improvement cycle.

6.1  Accessible Information

• Information which is able to be read or received and understood by the individual or group for which it is intended

6.2  Alternative Format

• Information provided in an alternative to standard printed or handwritten English, e.g. audio, braille or large print

6.3  Deafblind

• Deafblindness is a combined hearing and sight loss that causes problems with mobility, communication and access to information

Professionals providing this service should be aware of the following:

• Effective information and communication are vital components of a person-centred approach to care and support
• The Accessible Information Standard was introduced to standardise how organisations consistently meet communication needs of individuals
• There are 5 steps to the Accessible Information Standard. These are identify, record, flag, share and act
• The standard dovetails alongside equality and diversity and data protection legislation
• The standard is mandatory for NHS and social care providers

People affected by this service should be aware of the following:

• Mariama Care T/A Kangaroo Healthcare recognises that you may have specific communication requirements and will ensure this is accommodated
• Mariama Care T/A Kangaroo Healthcare will ensure information is presented in an accessible way and, where appropriate, in a range of languages and formats that are easily used and understood
• Mariama Care T/A Kangaroo Healthcare will seek your feedback on information sharing as a means of improving its service

 

 

 

As well as the information in the ‘underpinning knowledge’ section of the review sheet we recommend that you add to your understanding in this policy area by considering the following materials:

Skills for Care – Care Certificate – Communication:

https://www.skillsforcare.org.uk/Developing-your-workforce/Care-Certificate/Care-Certificate.aspx National Register of Communication Professionals Working with Deaf and Deafblind People: https://www.nrcpd.org.uk

National Register of Public Service Interpreters:

https://www.nrpsi.org.uk/

The Royal National Institute of Blind people and Sense can offer further information about braille and communication formats:

RNIB – Braille: Tactile Codes:

https://www.rnib.org.uk/practical-help/reading/braille-and-moon-tactile-codes

Sense – Total Communication:

https://www.sense.org.uk/get-support/information-and-advice/communication/total-communication/

Action on hearing loss and Signhealth can provide resources for hearing loss: RNID – Hearing Loss:

https://rnid.org.uk/information-and-support/hearing-loss/ Signhealth – Who uses British Sign Language (BSL)? https://www.signhealth.org.uk/about-deafness/sign-language/ GOV.UK – Guidance – Accessible Communication Formats:

https://www.gov.uk/government/publications/inclusive-communication/accessible-communication-formats  The Stroke Association has produced an animated guide to communicating with people with aphasia, as well as a guidance sheet:

The Stroke Association – Aphasia Etiquette:

https://www.youtube.com/watch?v=hTh86NoQh7Q

The Stroke Association – Communication Problems After a Stroke:

https://www.stroke.org.uk/resources/helping-someone-communication-problems

Please refer to the QCS Resource Centre for useful Easy Read support, which includes:

• How to Create Easy Read Documents
• QCS Easy Read Template
• Accessible Information Flag

Please refer to the ‘Recite Me’ function within QCS Compliance Centre which can be accessed by clicking      on the person icon.

 

To be ‘ outstanding ’ in this policy area you could provide evidence that:

• Different formats of key policies such as the Complaints, Suggestions and Compliments Policy and Procedure are readily available for access
• Mariama Care T/A Kangaroo Healthcare actively advertises to any visitors that it can accommodate different communication needs and actively supports a culture that encourages people to disclose their needs
• Staff receive additional training in relation to communication skills, such as lipreading, sign language, use of electronic communication aids
• Records clearly state communication needs and audits demonstrate adherence to the standard
• Any feedback and suggestions received in relation to communication within Mariama Care T/A Kangaroo Healthcare is acted on in a timely manner as part of quality assurance processes
• The wide understanding of the policy is enabled by proactive use of the QCS App

 

 

 

 

The following forms are included as part of this policy:

Title of form	When would the form be used?	Created by
Accessible Information Flag – CR63	An optional form to be used in Care and Support Planning	QCS

 

		Access and Sharing Information
		You can locate my consent here:

 

 

 

 

 

 

 

Service User:	.
My Accessible Information Flag

 

Communication aids

Such as Pics of Pecs, Widget, Signs and Symbols

These are located here:

 

Support to Communicate effectively

An Advocate, Interpreter, Makaton, BSL, My Communication Passport

You will find these here:

 

Giving Information

Signs and Symbols, Audio Versions, Easy Read, Large Print, Braille etc

 

Communication Support Plan

Give a brief outline here of what is stated in the plan

You can locate this here:

 

 

 

Completed By:

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Date:

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