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Registration Number: {{org_field_registration_no}}

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Immunisation of People Policy

1. Purpose

The purpose of this policy is to ensure that all individuals supported by {{org_field_name}} are encouraged and supported to access immunisations relevant to their personal health needs, age, and risk profile. Immunisation plays a critical role in protecting people from preventable diseases, supporting public health, and maintaining service continuity. This policy supports compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in particular Regulation 9 (Person-centred care), Regulation 11 (Need for consent), Regulation 12 (Safe care and treatment), Regulation 13 (Safeguarding service users from abuse and improper treatment), and Regulation 17 (Good governance). It also supports compliance with current national immunisation guidance, including the UK Health Security Agency (UKHSA) Green Book, NHS vaccination programme guidance, and relevant Care Quality Commission (CQC) guidance.

2. Scope

This policy applies to all people supported by {{org_field_name}} who may be eligible for, or may benefit from, immunisation as part of routine, seasonal, outbreak-response, or risk-based vaccination programmes.

It applies to all staff involved in identifying need, providing information, obtaining and recording consent, making referrals, arranging appointments, supporting attendance, updating care plans, managing associated risks, and recording outcomes.

Where vaccines are administered on site, this policy also applies to staff involved in facilitating or supporting vaccine administration. Vaccines will only be administered by an appropriately authorised and competent practitioner, or by staff acting under a lawful and valid direction or protocol in accordance with current law and national guidance.

This policy should be read alongside the service’s medicines management, infection prevention and control, consent and mental capacity, safeguarding, incident reporting, and confidentiality/data protection policies.

3. Related Policies

• CH07 – Person-Centred Care Policy
• CH11 – Safe Care and Treatment Policy
• CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CH17 – Infection Prevention and Control Policy
• CH34 – Confidentiality and Data Protection (GDPR) – Service User Policy
• CH39 – Mental Capacity and Deprivation of Liberty Safeguards Policy

4. Policy Statement and Responsibilities

Commitment to Supporting Immunisation

{{org_field_name}} recognises that immunisation is an important part of preventing avoidable illness, reducing the risk of outbreaks, protecting individual and public health, and supporting continuity and safety of care within the service. We will promote and support access to immunisation in a person-centred way, in line with current national programmes and guidance issued by the UK Health Security Agency (UKHSA), NHS England, the Joint Committee on Vaccination and Immunisation (JCVI), and local NHS/public health partners.

Support may include routine, seasonal, outbreak-response, or clinically indicated immunisations, such as influenza, COVID-19, pneumococcal, shingles, RSV, and any other vaccines for which the person becomes eligible under current national guidance. The vaccines offered will not be treated as a fixed list and will be reviewed in line with current guidance.

Risk Assessment and Identification

During the initial assessment, care planning, admission, transfer into the service, and at regular review, the Registered Manager or delegated competent person will ensure that the following are considered and documented:

• whether the person may be eligible for any routine, seasonal, outbreak-response, travel-related or clinically indicated immunisation;
• the person’s known vaccination history, where available;
• relevant medical history, allergies, contraindications, cautions, previous adverse reactions, current health status, and any reasonable adjustments required;
• the person’s views, wishes, beliefs and preferences about immunisation;
• any communication needs, sensory needs, cognitive impairment, anxiety, distress, trauma history, or cultural/religious considerations that may affect decision-making or access;
• the risks to the individual and, where relevant, to others of delayed, declined or missed vaccination;
• the arrangements needed to enable access to vaccination safely, including appointment booking, transport, liaison with relatives or representatives, support during attendance, and post-vaccination observation or follow-up where required.

This information must be reflected in the person’s care plan, risk assessment and review documentation, and updated whenever circumstances or national guidance change.

Consent and Capacity

In accordance with Regulation 11 and the Mental Capacity Act 2005, immunisation will only be supported or arranged on the basis of valid, informed and appropriately recorded consent or other lawful authority.

Where the person has capacity to make the relevant decision, staff will:

• provide information in a format the person can understand;
• explain the purpose, expected benefits, known risks, possible side effects, and practical arrangements for vaccination;
• support the person to ask questions and make their own decision free from coercion; and
• clearly record the decision, including where the person declines vaccination.

Where there is doubt about capacity to consent to a particular vaccination decision, a decision-specific capacity assessment must be completed and recorded.

If the person lacks capacity for the relevant decision, any decision to proceed must be made in accordance with the Mental Capacity Act 2005 and must be recorded as a best-interests decision. This must include consultation with those involved in the person’s care and welfare, including family members, advocates, attorneys or deputies where appropriate. Family members do not consent on behalf of a person unless they hold lawful authority to do so.

The least restrictive option must always be considered. A capacitous person’s refusal of vaccination must be respected, even where others disagree, unless another lawful basis applies.

Staff must not use pressure, blanket rules or misleading information to secure agreement. The consent discussion, capacity assessment where applicable, best-interests process where applicable, and final decision must all be recorded clearly.

Equality, Communication and Accessible Information

{{org_field_name}} will make sure that people are not disadvantaged in accessing immunisation support because of disability, sensory loss, cognitive impairment, language, literacy, culture, religion, trauma history, anxiety, or any other protected or individual characteristic. Information about vaccination will be provided in a way the person can understand, and reasonable adjustments will be made to support informed decision-making and access.

Coordination with Healthcare Professionals

{{org_field_name}} will work in partnership with GPs, primary care networks, community nursing teams, pharmacists, vaccination providers, local NHS services, and other relevant professionals to support timely and safe access to immunisation.

This includes:

• confirming which provider is clinically responsible for assessing suitability and administering the vaccine;
• sharing relevant information lawfully and on a need-to-know basis, with consent or other lawful basis where required;
• arranging appointments in the home or community as appropriate;
• supporting outbreak-response or seasonal vaccination activity in line with current national and local guidance;
• ensuring that roles, responsibilities and escalation routes are clear where more than one organisation is involved.

Where vaccines are administered within the service, the Registered Manager must ensure that the arrangements are lawful, clinically appropriate, and clearly documented. Vaccines are prescription-only medicines and must only be administered under valid authorisation in accordance with current law and national guidance. The service must be clear who is responsible for ordering, storing, handling, administering, recording and following up the vaccine process.

Vaccine Administration Arrangements

Where vaccination is delivered on site, the Registered Manager must ensure there is a clear written arrangement setting out who is clinically responsible, who is authorised to administer the vaccine, how consent and eligibility are confirmed, how records will be completed, and how urgent concerns or adverse reactions will be escalated. Vaccines must only be administered under lawful and valid authorisation and in line with current national and local clinical guidance. The service must not assume that a vaccine can be given simply because it has been delivered to the home or requested by staff or relatives.

Supporting People Through the Process

Care staff will provide person-centred support before, during and after vaccination by:

• giving information in accessible formats, including plain language, large print, translated material, visual prompts or other communication aids where needed;
• identifying and making reasonable adjustments for communication, cognitive, sensory, physical, emotional or behavioural needs;
• preparing the person for the appointment in a calm and supportive way;
• supporting transport, attendance, familiar staff support, or access to in-home vaccination where appropriate;
• observing for and responding to any immediate concerns after vaccination in line with the instructions of the administering clinician and local procedure;
• escalating any deterioration, adverse effect, medication incident or safeguarding concern without delay.

All support provided and any concerns arising must be recorded in the care record.

Record-Keeping and Confidentiality

Accurate, complete and contemporaneous records must be maintained in relation to immunisation decisions, support provided, outcomes and follow-up actions. Records must be stored securely and handled in accordance with the UK GDPR, the Data Protection Act 2018, confidentiality requirements, and the organisation’s information governance procedures.

The care record should include, as applicable:

• the vaccines for which the person may be eligible or has been assessed;
• the information given to the person and/or their representative;
• the person’s wishes, consent decision, refusal, or request to defer;
• any capacity assessment and best-interests decision-making record;
• the date of vaccination, vaccine type, and provider;
• where the vaccine is administered within or for the service and this information is available, the batch number, site of administration, route, and name/designation of the administering practitioner;
• any immediate or delayed adverse effects, aftercare advice, referrals, and follow-up actions;
• any review of risk where vaccination is declined or delayed.

Immunisation information should also be reflected in care plans, risk assessments and handover information where relevant to the safe delivery of care.

Adverse Events, Incidents and Escalation

Any suspected adverse reaction, medicine incident, documentation error, near miss, deterioration following vaccination, or failure in the immunisation support process must be responded to promptly and reported in line with the organisation’s incident reporting, medicines management and safeguarding procedures. The Registered Manager must ensure that appropriate healthcare professionals are informed without delay, that immediate risks are managed, and that learning is identified, recorded and acted upon through governance processes.

Infection Prevention and Safeguarding

Immunisation forms part of the service’s wider approach to infection prevention and control. The service will assess and manage the risk of transmissible infection in line with current national guidance and the organisation’s infection prevention and control procedures.

A person’s decision to refuse or defer vaccination must be respected where they have capacity to make that decision. Refusal must not in itself be treated as a safeguarding concern. However, staff must consider whether there are any indicators of coercion, undue influence, neglect, discriminatory practice, misinformation being deliberately used to control the person, or failure to act in the person’s best interests where they lack capacity. Any such concerns must be escalated promptly under the safeguarding policy.

Where vaccination is declined or delayed, the service must review and document any additional infection prevention and risk reduction measures required to protect the person and others.

Staff Training and Guidance

Staff will receive role-appropriate training, supervision and guidance on:

• the purpose and value of immunisation in adult social care;
• current national immunisation guidance relevant to the people supported by the service;
• person-centred communication, accessible information and reasonable adjustments;
• lawful consent, the Mental Capacity Act 2005, best-interests decision-making, and respecting refusal;
• recognising and escalating vaccine hesitancy, safeguarding concerns, adverse effects and incidents;
• record-keeping, confidentiality and information sharing requirements.

Where staff are involved in any aspect of on-site vaccine handling or administration, the Registered Manager must ensure that only appropriately trained, competent and authorised staff undertake those tasks, in line with current law, professional standards, and local clinical arrangements.

Refresher training and updates will be provided whenever guidance changes, new campaigns are introduced, incidents identify learning needs, or competence concerns are identified.

Monitoring and Audit

The Registered Manager is responsible for ensuring effective governance of immunisation support arrangements. This includes:

• auditing care records to check that eligibility, discussions, consent, refusals, capacity assessments, best-interests decisions and outcomes are properly documented;
• reviewing whether referrals, appointments and follow-up actions are completed in a timely way;
• monitoring patterns of uptake, refusal, delay or missed opportunities to identify barriers and learning;
• reviewing incidents, complaints, adverse events and safeguarding concerns relating to immunisation support;
• ensuring that lessons learned are shared with staff and used to update care planning, risk management and service procedures;
• seeking assurance that any on-site vaccination arrangements are lawful, safe and clearly governed.

Audit findings and actions will be reviewed through the service’s governance systems and retained as evidence of compliance with Regulation 17.

5. Policy Review

This policy will be reviewed at least annually and sooner if there are changes to legislation, CQC guidance, the UKHSA Green Book, NHS vaccination programme guidance, local vaccination arrangements, or learning from incidents, complaints, safeguarding enquiries or audits.

The Registered Manager is responsible for ensuring that revised guidance is communicated to staff promptly and that necessary changes are embedded in care planning, practice and governance systems.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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