Total Communication in Adult Social Care: Building a Consistent, Auditable System
In adult social care, communication is not a “soft” theme—it is a safety-critical delivery system. When people cannot reliably understand information, express preferences, or make themselves understood, risk increases and outcomes fall away. A Total Communication approach brings consistency: the team agrees how they will communicate, how they will record it, and how they will sustain it through training and governance. This article sits alongside Communication, Accessible Information & Total Communication and your wider Core Principles & Values practice standards, focusing on what it looks like operationally when it is done properly.
What “Total Communication” means in regulated adult social care
Total Communication means using multiple methods—speech, visuals, objects, gesture, writing, signs, symbols and technology—so the person has more than one route to understand and to express themselves. The key point is consistency: it is not each worker “having a go”, it is an agreed approach that is trained, supervised, and evidenced.
In operational terms, Total Communication should be visible in:
- Support plans and day-to-day guidance (what to use, when, and how)
- Risk assessments and consent pathways (how the person understands and indicates choice)
- Staff induction and competency checks (what “good” looks like)
- Quality assurance activity (spot checks, audits, and learning loops)
Where Total Communication usually fails (and how to prevent it)
Failure point 1: “Tools without a shared method”
Teams buy symbol packs or print picture cards, but do not define the method. Staff then improvise, meaning the person experiences different prompts and expectations across shifts. Prevent this by building a “communication standard” for each person: what communication supports are used, how to introduce them, and how to check understanding.
Failure point 2: “It sits in the plan but not in the shift”
Total Communication becomes a paragraph in the plan but is not embedded in routines (morning checks, medication, money management, community access). Prevent this by identifying “high-risk communication moments” and writing step-by-step prompts into daily workflow guidance.
Failure point 3: “No one audits it”
If communication practice is not audited, it will drift. Prevent this by adding communication checks to existing assurance—supervision, spot checks, incident reviews, and complaint learning—so it is part of normal governance rather than an extra project.
Operational Example 1: Supporting consent and capacity in daily health tasks
Context: A person with cognitive impairment following ABI required support with medication prompts and routine health monitoring. Verbal explanations alone led to distress and refusals, increasing risk and triggering avoidable escalations.
Support approach: The team implemented a Total Communication pathway for “health decisions”, linking communication prompts to the person’s capacity and consent recording. They agreed consistent language, visuals, and confirmation steps.
Day-to-day delivery detail:
- A one-page “health communication passport” sat at the front of the daily record and in the handover template.
- Staff used a two-step method: (1) show a symbol/object cue (e.g., blister pack and a “take” symbol), (2) give a short spoken phrase, then pause.
- Understanding was checked using a consistent “teach-back” prompt: the person pointed to “now/later” and “yes/no” cards, then staff recorded the response verbatim.
- If refusal occurred, staff followed a pre-agreed de-escalation script and offered two alternative timings, documenting which method reduced distress.
How effectiveness/change is evidenced: The service tracked (a) refusals, (b) incidents of distress linked to medication, (c) time taken to complete the routine, and (d) consistency across staff via spot checks. Over four weeks, refusals reduced and records showed clearer consent pathways (including when best-interests decision-making was required).
Operational Example 2: Reducing distress during personal care through predictable communication
Context: An older person receiving homecare support became distressed during personal care, with staff reporting “resistance” and inconsistent approaches. The person had hearing loss, anxiety and fluctuating cognition.
Support approach: The provider introduced a Total Communication “predictability routine” for personal care: the same sequence, the same prompts, and the same options offered every visit.
Day-to-day delivery detail:
- Carers used a laminated visit sequence card: greeting, choice of room, water temperature check, clothing options, step-by-step prompts.
- Key instructions were written in large font with simple words and paired with gestures; staff reduced background noise (TV/radio off) and positioned themselves in the person’s visual field.
- Staff used “one instruction at a time” with a pause, then offered the person a choice card (“wash face first” / “wash hands first”).
- A short observation note was recorded after each visit: what prompts worked, what triggered distress, and what adjustments were used.
How effectiveness/change is evidenced: The provider measured frequency of distress episodes, missed tasks, and call duration variance. They also used family feedback and staff supervision notes to confirm consistency. Within a month, calls stabilised, fewer escalations occurred, and staff could evidence “least restrictive” practice through recorded choices and reduced distress.
Operational Example 3: Building communication into community access and travel training
Context: A person in supported living wanted to attend a community volunteering role but experienced anxiety and confusion on public transport. Incidents occurred when staff changed plans without clear explanation.
Support approach: The service built a Total Communication travel system: visual route planning, contingency options, and a consistent method for explaining change.
Day-to-day delivery detail:
- A visual journey board showed: “home → stop → bus number → stop → venue”, with photographs of key landmarks.
- Staff rehearsed “change scripts” using a simple three-part structure: what has changed, what stays the same, what choice the person has now.
- Contingencies were pre-agreed (alternate bus, taxi threshold, safe places) and recorded as prompts staff must follow.
- After each journey, the person and staff completed a quick debrief using emotion cards and “what helped” prompts.
How effectiveness/change is evidenced: The provider recorded incident frequency, successful journeys, and the person’s reported anxiety rating using simple scales. They reviewed data in monthly outcomes meetings and adjusted the journey plan when changes triggered repeated distress.
Commissioner expectation: consistent, measurable reasonable adjustments in delivery
Commissioner expectation: Commissioners expect providers to demonstrate that communication adjustments are not ad hoc. They will look for evidence that adjustments are designed into delivery (care planning, staffing, supervision) and that the provider can show impact—reduced incidents, improved outcomes, fewer complaints, and clearer consent pathways. In contract management, “we use picture cards” is weak; “we have a defined communication method, trained staff, audited compliance, and outcome evidence” is what stands up.
Regulator / Inspector expectation (CQC): communication as a quality and safety control
Regulator / Inspector expectation (CQC): Inspectors will test whether people can understand information and be involved in decisions, and whether staff adapt communication to needs. They will also look at whether poor communication contributes to incidents, restrictive practice, or safeguarding concerns—and whether the provider learns. Strong services can show consistent tools, staff confidence, and records that reflect genuine involvement (not generic statements).
Governance and assurance: making Total Communication “stick”
1) Competency-based training and sign-off
Induction should include practical observation: staff demonstrate the person’s communication method, not just complete e-learning. Use a short competency checklist: positioning, pace, choice prompts, understanding checks, and recording standards.
2) Supervision and spot checks that include communication
Add a communication line item to supervision templates: “What adjustments have you used this month? What worked? What didn’t? What have you learned?” Spot checks should include a brief “communication audit” (e.g., did staff follow the agreed prompts, and is this reflected in records?).
3) Record standards: evidence, not narrative padding
Records should show the method used and the person’s response. Good recording includes direct responses (“pointed to ‘later’ card”, “selected option A”), and notes what staff changed to reduce distress. This supports outcomes evidence and safeguards the provider if decisions are challenged.
4) Quality reviews linked to risk and safeguarding
If incidents occur (distress, refusal, missing medication, allegations), review communication factors explicitly: did the person understand? Were choices offered? Did staff follow the method? Are there barriers (hearing, vision, cognition, sensory overload) that need adjustment? Document learning and actions.
Practical implementation checklist
- Define each person’s communication method (tools + steps + understanding checks)
- Identify “high-risk communication moments” and embed prompts into daily workflows
- Train and sign off competence through observation, not just theory
- Audit through spot checks, supervision, incident learning and record reviews
- Evidence impact using practical measures (incidents, refusals, outcomes, feedback)