Communicating with Service Users Best Practice

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Status: Approved Document type: Procedure

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Contents 1 Purpose…………………………………………………………………………………. 3 2 Related Documents…………………………………………………………………… 3 3 Confidentiality and Security………………………………………………………… 4 4 Record Keeping……………………………………………………………………….. 4 5 Accessible Information Standard………………………………………………….. 4 6 Procedure………………………………………………………………………………. 5 6.1 Letters………………………………………………………………………………. 5 6.2 Email………………………………………………………………………………… 8 6.3 Text………………………………………………………………………………….. 9 6.4 Telephone Calls……………………………………………………………………. 11 6.5 Voicemail……………………………………………………………………………. 12 6.6 Fax…………………………………………………………………………………… 12 6.7 Instant Messaging Apps…………………………………………………………... 13 7 Definitions……………………………………………………………………………… 14 8 References……………………………………………………………………………... 15 9 How this procedure will be implemented………………………………………… 16 9.1 Training Needs Analysis…………………………………………………………... 16 10 How the implementation of this procedure will be monitored………………... 17 11 Equality Analysis Screening Form………………………………………………… 18 12 Document Control……………………………………………………………………. 22 13 Appendix 1 – Copying Letters Process…………………………………………… 23 14 Appendix 2 – Terms and Conditions of Use for using email to

Communicate Clinical Information to Service Users…………………………... 24

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1 Purpose 1.1 Trust service users have the right to be involved in and informed of the care they

receive. There are several ways in which Trust staff can communicate with service users: • Letter • Email • Text • Telephone calls • Fax • Instant Messaging Apps

1.2 Make service users aware of all the options that are available for communication. 1.3 Following this procedure will help Trust staff and service users to:

• Understand the different methods of communication the Trust allows. • Make a shared decision about the most appropriate method of communication. • Understand how to use each communication method.

1.4 Communication is important because it makes service users feel connected, reduces

their isolation and aids recovery. 2 Related Documents This procedure describes what you need to do to implement the Confidentiality and Sharing Information Policy when communicating with service users.

The Confidentiality and Sharing Information Policy describes the conflict between staff obligations to preserve patient confidentiality and the need for information to be shared to provide the best care for our service users. You must read and understand this policy before carrying out the procedures described in this document.

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This procedure also refers to the Trust’s: Information Governance Policy Records Management – Minimum Standards for Clinical Record Keeping Records Management – Minimum Standards for Corporate Record Keeping Clinical Record Keeping Competency Workbook Telephone Usage Policy Email Policy Email Procedure Records Management and Safe Haven Policy Accessible Information Standard Harm Minimisation Policy Mobile Phone Policy for Service Users and Visitors

3 Confidentiality and Security 3.1 When contacting service users/parents/carers, confidentiality and security must be

the most important consideration, with staff following relevant legislation, professional Codes of Conduct and NHS Guidance: • The General Data Protection Regulation 2016 and The Data Protection Act 2018 • The NHS Plan (2000) • NHS Guidance: Copying Letters to Patients (2003)

3.2 It is essential that the use of information is in line with data protection law. Personal information must be processed in a lawful, fair and transparent manner. The use of personal data and information by an organisation must be understood by that individual. An NHS organisation or service provider must explain to the individual: • What information they need about them; • For what purpose; • Who the information may be shared with; and • What they will do with that information, in terms of compliance with data

protection law This information is available to service users through a privacy notice.

3.3 The Information Governance Team at NHS England recognise that both service users and professionals have concerns around the use of digital technology, ie email and text, in terms of confidentiality and security, which can pose a barrier to these methods being used as routine practice.

3.4 The Trust has arrangements in place to minimise the risk of breaches in privacy, including, Close Monitoring and Break Glass on the electronic patient record system.

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4 Record Keeping 4.1 All communication between staff and service users must be recorded in the clinical

record (Paris primarily, but in paper records for some clinical teams). Procedures for recording the different methods of communication are referred to within each section of this document.

4.2 The detail of what is recorded will depend upon the type of contact, eg whether it is

on a 1-1 basis or group work. However, if a service user discloses anything considered to be a risk this must be recorded in their record regardless of the type of contact.

5 Accessible Information Standard 5.1 The Patient Demographics in Central Index within Paris allows you to record service

users’ communication needs. This ensures that the Trust complies with the Accessible Information Standard. The standards aims to provide a consistent approach to identifying, recording, flagging, sharing and meeting the information and communication needs of service users and/or parents/carers, where those needs relate to a disability, impairment or sensory loss. All users must record accessible information onto Paris; information about how to do this can be found in this Briefing Sheet.

5.2 This is of most relevance to those who are blind, d/Deaf, deafblind and/or who have

a learning disability. It will also support anyone with information or communication needs relating to a disability, impairment or sensory loss, eg people who have dyslexia, aphasia or a mental health condition which affects their ability to communicate.

5.3 If you are using another system, eg IAPTUS, you must take account of service user

information/communication needs and record information in the appropriate place. 5.4 AIS training is available through ESR. It is recommended that staff complete this so

they can better understand the needs of service users.

6 Procedures

6.1 Letters 6.1.1 The NHS Plan of 2000 proposed that letters between clinicians about an individual

patient’s care will be copied to the patient as of right. 6.1.2 The potential benefits of copying letters to service users can be achieved by writing

letters in a way which communicates compassion, care and respect. Use

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appropriate language and write in a way which is easy to understand. Avoid writing things and using language which the service user might find offensive. Use language which acknowledges the whole person rather than just their diagnosis or symptoms. The accuracy of records, the level of trust and the therapeutic relationship between the professional and service user may be enhanced by co-producing the letter and agreeing the content of the letter together before it is sent.

6.1.3 However, not all service users wish to receive copies of letters and not necessarily for every consultation.

6.1.4 At each consultation that generates letters ask the service user if they wish to receive a copy of that letter. Letters will not be copied to service users if the health professional has evidence to suggest that the service user, or anyone else, could be seriously harmed by the disclosure of a letter.

6.1.5 Carry out a ‘serious harm test’ to identify whether the disclosure of the health

information would be likely to cause serious harm to the physical or mental health of the service user or another individual.

6.1.6 When carrying out the serious harm test the clinician may wish to consider whether:

• The multidisciplinary team should be consulted regarding what constitutes serious harm based on the known information about the individual and recorded information.

• Known risks on assessment and risk documents, alerts, etc have been reviewed, including historical records, any documented requests not to share information with the individuals.

• There is evidence that clinical information has been withheld in the past and the reasons why this decision taken stated.

• Consideration has been given as to the service user’s known current mental state and whether the request for information is linked.

6.1.7 Even if the clinician consults with others or takes their views into account, it is the

clinician, as the appropriate health professional, and no-one else, who must give the opinion about whether the serious harm test is met or not, or met in part.

6.1.8 Please note that service users may change their mind about receiving copies of

letters at any given time and their wishes must be respected.

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6.1.9 Record the service user’s decision in their clinical record, as follows: • Paris – type in the ‘Sharing Details’ box within the Recording Patient Consent

Status entry, eg “discussion taken place with regard to sharing letters; service user does/does not wish to receive copies”.

• If the service user wishes to receive copy letters, the healthcare professional who is writing the letter should make the necessary arrangements, including confirming where the letter should be sent to, eg home address, given to at next appointment and also in what format.

A flowchart has been developed to guide staff through the process (Appendix 1).

6.1.10 Write all letters in an appropriate format and language, based on individual requirements, and use ‘plain English’ so that they are easily understood by both professionals and lay people. Where possible, avoid using technical terminology; however, if this cannot be avoided, explanations should be given. Do not share any test results or diagnoses via letter until a discussion is held in person. Refer to the Trust’s Minimum Standards for Clinical Record Keeping.

6.1.11 Letters should reinforce and confirm the information that was given in discussion

with the service user in the consultation, or in the consultation with the receiving professional.

6.1.12 No new information should be included in the letter, which might surprise or distress

the service user. 6.1.13 Mark all copy letters to service users ‘Private and Confidential’ and address using

their full name, rather than initials. Check that there is not more than one person with the same name living at the address the letter is being sent to. For example, there might be a father and son or mother and daughter who share the same name. If this is the case, make it clear who the recipient is.

6.1.14 Check the service user’s address regularly to ensure it remains accurate and up-to-

date. 6.1.15 Include a return address on the reverse of the envelope to ensure that a letter sent

to an incorrect address can be returned to the service from where it was sent. However, as some service users do not like to be identified as accessing mental health services, use only the bare minimum of the address without any reference to TEWV, the NHS or include a logo.

Example:

Merrick House Seaside Lane Easington Village County Durham SR8 3DY

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6.1.16 When copy letters are to be sent, provide them in a format that takes into account the service user’s capacity to read, comprehend and safeguard the information.

6.1.17 Where the service user is not legally responsible for their own care, eg a young

child or child in care, letters should be copied to the person with legal responsibility. Ask young people aged 16 and 17 to give their own agreement to copy letters. It is the healthcare professional’s responsibility to assess younger children’s competence to understand and make a decision.

6.1.18 When a service user lacks mental capacity to make a decision, eg due to dementia

or learning difficulties, it will be noted within their records who will act on their behalf – this is not necessarily a family member and could be an independent advocate. Avoid making ‘blanket’ assumptions about mental capacity. The Mental Capacity Act Code of Practice (2005) explains what is meant by capacity and provides guidance on how to assess whether someone has the capacity to make a decision.

6.1.19 Letters sent to the home address of service users in prison must not contain dates

of future appointments as this is considered to be a security risk. 6.1.20 Do not send copy letters when:

• The service user does not want a copy; • There is substantial evidence why the letter should not be shared (the casenote

entry must explain the rationale and provide substantial evidence why the letter should not be shared);

• The letter includes information about a third party who has not consented to share information;

• Special safeguards for confidentiality may be needed.

6.2 Email

6.2.1 The Trust allows email communication between staff and service users, preferably sent via a generic group mailbox and only administrative or business operational information, eg appointment reminders or to identify a reason for a service user not attending an appointment.

6.2.2 The Trust’s Information Security Team would not recommend emailing clinical information to service users because it is not a secure method of information transfer. However, if service users choose to use this as a method of sending person identifiable information (PII) then the Trust will allow services to do so.

6.2.3 Ask the service user if they wish to receive emails with attached clinical documents. If they wish this to take place then the options for doing so need to be explained: • Encrypted transfer – this is the Trust’s preferred option. The service user will

need to register with the NHS mail encryption service; registration is free. Guidance about this can be found in section 5.2.3 of the Trust’s Email Procedure – any queries on the use of the NHS mail encryption service should

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be directed to the Information Security Team via email to tewv.informationsecurity@nhs.net.

• Un-encrypted (non-secure) transfer – documents are emailed without using the NHS mail encryption service. This is not a secure method of information transfer. The service user must accept the risks associated with the transfer of information in this format.

6.2.4 Explain the risks of using email to the service user – refer to the Terms and Conditions of Use attached at Appendix 2. In particular, ensure the service user fully understands that email must not be used to communicate issues around crisis or other aspects of their health to the team from which they are receiving treatment.

6.2.5 Document the discussion about the use of email in the service user’s record and record consent for communication by email in the Paris Consent module. Record which option of email transfer has been chosen – secure (encrypted) or non-secure (un-encrypted). If the service user lacks capacity, the person acting on their behalf needs to be the person who consents. Service users, or their representative, should sign the Terms & Conditions of Use document (Appendix 2).

6.2.6 Before any PII is sent to a service user, check that their email address is correct; send a test email with instructions that the service user confirms receipt by contacting the clinical team by telephone.

6.2.7 Email exchanges are an important part of a service user’s clinical records; record in Paris and include the date email(s) are sent/received, by whom and the subject matter.

6.2.8 If you are using email to communicate with service users you must follow these

principles: • Copy and paste the text from the email into a Paris casenote entry. Save the email

onto a shared network team folder so only those staff that ‘need to know’ have access. The folder will need to be named ‘patient emails’ and you will need to create a folder for each service user and name it according to their Paris ID.

• It is important to save the whole email as it contains important information called ‘metadata’, eg date and time email was sent. Metadata is needed to maintain the legal admissibility of a record. Service user communication emails are records and their legal admissibility needs to be preserved.

• Emails are records and must be managed consistently. More service users are requesting access to emails through their Right of Access under data protection laws. Emails must therefore be retrievable.

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6.3 Text

6.3.1 Text messaging is now a communication method used by millions; it has many uses in healthcare – reminders, issuing advice, making appointments and requesting prescriptions.

6.3.2 The Trust supports the use of text messaging, also known as ‘SMS’ (Short

Messaging Service), as a means of communicating with service users, subject to compliance with this procedure and by establishing locally agreed processes.

6.3.3 Communicating with service users using text messaging can be done using either

Trust mobile phones or via NHS Mail. Using NHS mail involves a cost each time it is used. Contact the Information Service Desk for details of costs. You must complete an application form to make use of this service. Once this is approved you will receive a copy of the Information Department’s How to Send SMS Text Messages from NHS Mail.

6.3.4 The Royal College of Nursing’s guide on the use of a text messaging service states that there are three different ways to use text messaging and some local discussions need to take place about what type is suitable: Simple This type of messaging service is initiated by the service provider and is usually a reminder or question about an appointment. Specific Automated: A service user initiates a request for information or signposting to other services and receives a programmed response. Personal Response: This is initiated by the service user to obtain a response about personal health. It can lead to a consultation or referral to other service providers. Serious This describes a disclosure made by a service user about an event or cause for concern. Local practitioners need to be in place to deal with these potential situations and practitioners need to have access to supervision.

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6.3.5 Staff may send texts to service users using either their work mobile phone or one that is used jointly by their team.

6.3.6 If the service user and member of staff providing their care identify direct access to the staff member’s work mobile phone as a method of communication, this must be written into the co-produced care plan, which is signed by both parties and reviewed on a regular basis. Any risks of this method of communication must be documented.

6.3.7 The service user should be provided with, and understand, terms of use for communicating via text message, such as: • Communicating by text will only be carried out for administrative or business

operational information, eg appointment reminders or to identify a reason for a service user not attending an appointment.

• The mobile phone will only be switched on between 9am-5pm; • If a text is sent and a response is not received, the service user should use

another communication method to contact the service, eg the team office number;

• If a service user needs to talk to someone in a crisis, provide them with the Crisis Team telephone number.

6.3.8 Record the service user’s decision to communicate by text in their clinical record, as follows: • Type in the ‘Sharing Details’ box within the Recording Patient Consent Status

entry, eg “discussion taken place with regard to communicating via text; service user does/does not wish to communicate in this way”.

6.3.9 Recording a service user’s mobile phone number in clinical records should not be regarded as their consent to use text messaging as a means of communication.

6.3.10 The use of ‘text-speak’, abbreviations or symbols/emoji’s are not permitted. If a service user sends a text using any of these, ask for clarification – do not make assumptions or guesses as to their meaning.

6.3.11 Do not use predictive text as this can cause unintended modifications to words

which may change the meaning of the message. 6.3.12 Do not use inappropriate language in text messages that could cause offence, such

as swearing. Report the receipt of any such messages via Datix with full details, and record a verbatim transcription in the service user’s clinical record.

6.3.13 Never use text messages to convey personal or sensitive information.

6.3.14 Check the mobile phone number is correct – confirm with service user when discussing the use of text messaging and regularly check the number is still in use.

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However, explain to the service user that it is their responsibility to inform the Trust should their mobile number change.

6.3.15 Named healthcare professional(s) should be responsible for a specified mobile phone to maximise confidentiality.

6.3.16 Do not use text messages to pass on information that is required immediately as

there can be delays in the delivery of messages. This should be made clear to any service user who requests that texts be used as a form of communication.

6.3.17 Record all communications by text by transcribing them into the clinical record,

including the date, time sent/received and the phone number it was sent to/from. When this is done, delete the text from the mobile phone.

6.3.18 If you do not have access to Paris, eg unpaid Peer Support Worker, any communication received by text that needs to be recorded in the clinical record must be done by a the service user’s Care Co-ordinator or another member of the team.

6.3.19 Trust services must agree the need/benefit of using text messaging and formally

approve and document the implementation of the service in a local Standard Operating Procedure (SOP). Guidance on developing a SOP can be found here.

6.4 Telephone Calls

6.4.1 All service users have the right to privacy so, unless there is a justified reason to speak to someone on their behalf, eg they have given their consent or it is in their best interest, then do not speak with anyone other than the service user about the care they receive.

6.4.2 Consent must be obtained to use this method of communication. Confirm which telephone number(s) a service user wishes to be contacted on, eg home, work or mobile. Record the service user’s decision to communicate by telephone in Paris as follows: • Type in the ‘Sharing Details’ box within the Recording Patient Consent Status

entry, eg “discussion taken place with regard to communicating via telephone; service user does/does not wish to communicate in this way”. Also note if the service user is happy for messages to be left with anyone else who may answer the number(s) they have provided.

6.4.3 Explain to the service user that it is their responsibility to inform the Trust of any changes to telephone number(s).

6.4.4 Be mindful that some telephone service providers offer their customers the ability to

automatically reject incoming calls from ‘withheld’ or ‘private’ numbers. This can be

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manually overridden by dialling 9 (for an outside line) then the prefix 1470 before dialling the telephone number.

6.5 Voicemail 6.5.1 There are privacy risks associated with Trust staff leaving service users answer

phone messages unless they have given their consent to do so. If you do not have consent then any message left must not contain any clinical information nor mention the Trust or service.

6.5.2 Explain to the service user that any voicemail messages they leave on Trust

phones (either landline or mobile) will only be accessed during the hours of 9am-5pm.

6.5.3 Provide an alternative telephone number on Trust answerphone machines to

signpost service users to use out of-hours services, eg the local Crisis Team. 6.6 Fax 6.6.1 The Trust does not support the use of fax machines for communication with service

users. 6.6.2 Fax machines are now being phased out of use by the NHS by 2020 and will

become obsolete. 6.6.3 You must not communicate with service users by fax – you must find an alternative

but acceptable method of communication. 6.6.4 The Information Security Team can provide advice on safer ways of working with

information to reduce or remove the use of fax machines. Email tewv.informationsecurity@nhs.net for advice.

6.6.5 NHS Trusts are banned from purchasing fax machines from January 2019 and we

will be monitored quarterly until we are fax free.

6.7 Instant Messaging Apps

6.7.1 TEWV does not approve the use of any instant messaging App for business purposes at this point in time. This article provides some information.

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7 Definitions

Term Definition

Advocate • A person who supports someone who may otherwise find it difficult to communicate or express their point of view. Advocates can support people to make choices, ask questions and to say what they think.

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

Alternative format • Information provided in an alternative to standard printed or handwritten English, eg large print, braille or email.

Braille • A tactile reading format used by people who are blind, deafblind or who have some visual loss. Readers use their fingers to “read” or identify raised dots representing letters and numbers. Although originally intended (and still used) for the purpose of information being documented on paper, braille can now be used as a digital aid to conversation, with some smartphones offering braille displays. Refreshable braille displays for computers also enable braille users to read emails and documents.

d/Deaf • A person who identifies as being deaf with a lowercase ‘d’ is indicating that they have a significant hearing impairment. Many deaf people have lost their hearing later in life and as such may be able to speak and/or read English to the same extent as a hearing person. A person who identifies as being Deaf with an uppercase “D” is indicating that they are culturally Deaf and belong to the Deaf community. Most Deaf people are sign language users who have been deaf all of their lives. For most Deaf people, English is a second language and as such they may have a limited ability to read, write or speak English.

Deafblind • The Policy Guidance Care and Support for Deafblind Children and Adults (Department of Health 2014) states that “The generally accepted definition of Deafblindness is that persons are regarded as Deafblind “if their combined sight and hearing impairment causes difficulties with communication, access to information and mobility. This includes people with a progressive sight and hearing loss”

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Term Definition (Think Dual Sensory, Department of Health, 1995)”.

Easy read • Written information in an easy read format in which straightforward words and phrases are used supported by pictures, diagrams, symbols and/or photographs to aid understanding and to illustrate the text.

Mobile phone • A device that can make and receive telephone calls over a radio link whilst moving around a wide geographic area. In this case it is telephone calls and text messages only.

Text messages • Is the ability to send and receive electronic messages between two or more mobile or smart phones.

8 References Bhandari, N (2010), Readability – writing letters to patients in plain English. Royal College of Psychiatrists, BJPsych Bulletin [online] Data Protection Act (1998) Department of Health (2000) NHS Plan Department of Health (2003) Copying letters to Patients: Good practice guidelines Department of Health (2009) Good Practice in Consent: Implementation Guide (second edition) Medical Protection Society (2015) Communicating with Patients by Text Message Mental Capacity Act Code of Practice (2005) NICE (2012) Patient experience in adult NHS services: improving the experience of care for people using adult NHS services NHS England (2016) Accessible Information Standard: Using email and text message for communicating with patients – guidance from the Information Governance team at NHS England

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Nursing and Midwifery Council (2015) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives Royal College of Psychiatrists Faculty of Learning Disability (?year?) Copying clinical letters to patients: Guidelines for psychiatrists working with adults with learning disability Royal College of Nursing (2012) Using text messaging services: an RC guide on using technology to complement nursing practice Royal College of Nursing (2014) Use of digital technology: Guidance for nursing staff working with children and young people Royal College of Psychiatrists Faculty for the Psychiatry of Old Age (2004) Copying clinical letters to patients: Guidelines for old age psychiatrists

9 How this procedure will be implemented • This procedure will be published on the Trust’s intranet and external website.

• Line managers will disseminate this procedure to all Trust employees through a line management briefing.

9.1 Training Needs Analysis

Staff/Professional Group

Type of Training Duration Frequency of Training

All staff. Information Governance (Data Security Awareness – Level 1)

1 to 3 hours Annually.

All staff with Trust network access.

Network Training Up to half a day All new starters to the trust and staff returning to the trust after an absence of more than 12 months.

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10 How the implementation of this procedure will be monitored

Auditable Standard/Key Performance Indicators

Frequency/Method/Person Responsible

Where results and any Associate Action Plan will be reported to, implemented and monitored; (this will usually be via the relevant Governance Group).

1 Record keeping audit CPA Lead Officer Digital Safety and Information Governance Board

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11 Equality Analysis Screening Form Please note; The Equality Analysis Policy and Equality Analysis Guidance can be found on InTouch on the policies page Name of Service area, Directorate/Department ie, substance misuse, corporate, finance etc.

Information Governance Department, Nursing & Governance Directorate

Name of responsible person and job title Sharon Ross, Information Governance Support Officer

Name of working party, to include any other individuals, agencies or groups involved in this analysis

Accessible Information Standard Group Policy Review Task & Finish Group Theresa Parks, Information Governance Manager Andrea Shotton, Information Risk, Policy and Records Standards Manager Kate Hughes, Recovery Project Manager Jessica Lehane, Expert by Experience Co-ordinator

Policy (document/service) name Communicating with Service Users – Best Practice Guide

Is the area being assessed a; Policy/Strategy Service/Business plan Project

Procedure/Guidance Code of practice

Other – Please state Best Practice Guide

Geographical area Trustwide

Aims and objectives To provide staff with best practice guidance about the different methods that can be used to communicate with service users.

Start date of Equality Analysis Screening (This is the date you are asked to write or review the document/service etc)

11 October 2016

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End date of Equality Analysis Screening (This is when you have completed the analysis and it is ready to go to EMT to be approved)

29 January 2019

You must contact the EDHR team as soon as possible where you identify a negative impact. Please ring Sarah Jay or Tracey Marston on 0191 3336267/3542 1. Who does the Policy, Service, Function, Strategy, Code of practice, Guidance, Project or Business plan benefit?

The Procedure benefits the Trust, service users and their carers, staff (including agency/bank staff) and volunteers by ensuring that any communication is undertaken appropriately.

2. Will the Policy, Service, Function, Strategy, Code of practice, Guidance, Project or Business plan impact negatively on any of the protected characteristic groups below?

Race (including Gypsy and Traveller) No Disability (includes physical, learning, mental health, sensory and medical disabilities)

No Gender (Men, women and gender neutral etc.)

No

Gender reassignment (Transgender and gender identity)

No Sexual Orientation (Lesbian, Gay, Bisexual and Heterosexual etc.)

No Age (includes, young people, older people – people of all ages)

No

Religion or Belief (includes faith groups, atheism and philosophical belief’s)

No Pregnancy and Maternity (includes pregnancy, women who are breastfeeding and women on maternity leave)

No Marriage and Civil Partnership (includes opposite and same sex couples who are married or civil partners)

No

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Implementation of this best practice should support service users to feel more connected and less isolated.

3. Have you considered other sources of information such as; legislation, codes of practice, best practice, nice guidelines, CQC reports or feedback etc.? If ‘No’, why not?

Yes

No

Sources of Information may include: • Feedback from equality bodies, Care Quality

Commission, Equality and Human Rights Commission, etc.

• Investigation findings • Trust Strategic Direction • Data collection/analysis • National Guidance/Reports

• Staff grievances • Media • Community Consultation/Consultation Groups • Internal Consultation • Research • Other (Please state below)

4. Have you engaged or consulted with service users, carers, staff and other stakeholders including people from the following protected groups?: Race, Disability, Gender, Gender reassignment (Trans), Sexual Orientation (LGB), Religion or Belief, Age, Pregnancy and Maternity or Marriage and Civil Partnership

Yes – Please describe the engagement and involvement that has taken place

Trustwide consultation taken place. Feedback received from the Recovery Programme Team including Experts by Experience. Discussions held with Recovery Project Manager, Expert by Experience Co-ordinator and Peer Support and Recovery Expert by Experience Lead.

No – Please describe future plans that you may have to engage and involve people from different groups

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5. As part of this equality analysis have any training needs/service needs been identified?

No Please describe the identified training needs/service needs below

A training need has been identified for:

Trust staff Yes/No

Service users Yes/No Contractors or other outside agencies

Yes/No

Make sure that you have checked the information and that you are comfortable that additional evidence can provided if you are required to do so

The completed EA has been signed off by: You the Policy owner/manager: Type name: Theresa Parks

Date:29/01/19

Your reporting (line) manager: Type name: Louise Eastham

Date:29/01/19

If you need further advice or information on equality analysis, the EDHR team host surgeries to support you in this process, to book on and find out more please call: 0191 3336267/6542 or email: traceymarston@nhs.net

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12 Document control

Date of approval: 6 February 2019

Next review date: 6 February 2022

This document replaces: n/a

Lead: Name Title

Theresa Parks Information Governance Manager

Members of working party: Name Title

Sharon Ross Kate Hughes Jess Lehane Victoria Price

This document has been agreed and accepted by: (Director)

Name Title

Elizabeth Moody Director of Nursing and Governance

This document was approved by:

Name of committee/group Date

DS&IGB 6 Feb 2019

This document was ratified by: Name of committee/group Date

An equality analysis was completed on this document on:

29/01/2019

Change record Version Date Amendment details Status V1 06 Feb 2019 Creation of new document Approved

Ref Page 23 of 24 Title

13. Appendix 1 – Copying Letters Process Yes No No Yes No Yes Yes No * If a letter is not copied to the service user then record this decision in the casenote, provide a

rationale and provide substantial evidence why the letter has not been copied because this may be challenged by the service user

Assess whether the service user has capacity to decide whether they wish to receive copies of letters (Consider Mental Capacity and Gillick Competence)

At every consultation that generates a letter ask the service user if they wish to receive a copy of the letter and explain exclusions of serious harm and third party information.

Does the service user want a copy?

Record this decision in the healthcare record and review it when the next letter is due to be

generated

Write letter

Record this decision in the healthcare record and review it when the next

letter is due to be generated

Consider

Is there third party information which needs to be withheld? Is the content of the letter

likely to cause serious harm?

Redact elements that would cause harm or do not copy the letter *

Copy letter Copy letter Redact third party information or

seek consent for disclosure from the third party

prior to copying the letter

Ref Page 24 of 24 Title

14. Appendix 2 – Terms and Conditions of Use: the use of non-secure email to communicate clinical information to service users

If the service user insists on an un-encrypted (non-secure) email address for receiving clinical information then the following statements must be read with the service user or their representative and, once understood, their name, signature and date should be added to the bottom. This information should be used to produce service specific Terms and Conditions of Use: • I wish to receive clinical documents about my health by email through my email address

[insert email address of service user] • I understand that email is not a secure form of communication and that confidentiality

may not be maintained in an email. • I understand that email communication may result in infection by malware. • I accept that I cannot hold Tees, Esk and Wear Valleys NHS Foundation Trust liable for

the security and confidentiality of the emailed information. • I accept that I cannot hold Tees, Esk and Wear Valleys NHS Foundation Trust liable for

the security of the hardware that I use to communicate by email or liable for the cost of any remedial work resulting from any malware infections.

• I accept the risks associated with the un-encrypted transfer of information. • I understand that the Tees, Esk and Wear Valleys NHS Foundation Trust email address

must not be used for contact in a crisis. (If you need to contact the Trust in a crisis please use the Crisis Team telephone number for your area, which you will be provided with. .

• The Trust will not respond to emails sent to the Tees, Esk and Wear Valleys NHS Foundation Trust email address from which information is sent to you.

Service User Name: (BLOCK CAPITALS)

Service User Signature:

Date: