Consultation outcome

Making vaccination a condition of deployment in older adult care homes

Updated 9 November 2021

Applies to England

COVID-19 vaccination programme

1. The COVID-19 vaccination programme is the biggest vaccination programme in NHS history. As of 7 April 2021, almost 27 million people have had their first COVID-19 vaccine dose in England[footnote 1]. All people living in care homes, staff, health and social care workers, people aged 50 and over, and the clinically extremely vulnerable have been offered a vaccine. These groups account for 99% of deaths from COVID-19, meaning potentially thousands of lives will be saved. Analysis carried out by Public Health England suggests that the COVID-19 vaccination programme prevented 6,100 deaths in England up to the end of February 2021. The UK’s COVID-19 vaccines have been approved by the MHRA as being safe and effective in reducing the likelihood of COVID-19 infection and preventing severe disease in those who do catch the virus.

2. There is evidence to suggest that the vaccine also prevents those who catch the virus from infecting other people too, preventing the spread. The SIREN study provides strong evidence that vaccinating working age adults will substantially reduce asymptomatic and symptomatic SARS-CoV-2 infection and therefore reduce transmission of infection in the population. This study has shown an effectiveness against infection of 72% (95% CI 58 to 86) 21 days after first dose of Pfizer – this is similar to the effects seen in the AstraZeneca trials. The impact on transmission would therefore be expected to be at least this large. Protection against transmission may be slightly lower in older people, decline over time, or be lower against specific variants.

3. It is critical that we do everything we can to protect people who are most at risk of serious illness from COVID-19 and we know that vaccination is key to our route out of this pandemic. We have come a long way but there is still further to go.

Uptake of vaccination in older adult care homes

4. We never again want to return to a position of widespread outbreaks in care homes in which too many people living and working in care homes lost their lives. The Joint Committee on Vaccinations and Immunisation (JCVI) identified people living in older adult care homes and their staff, as the top priority group for vaccine rollout.

5. The independent Scientific Advisory Group for Emergencies (SAGE) Social Care Working Group has highlighted that people living in care homes have been significantly impacted by the COVID-19 pandemic due to a combination of a heightened risk of severe outcomes following COVID-19 infection and the risk of outbreaks in these closed settings. Ensuring very high levels of vaccination of people living and working in these settings is an essential public health intervention for a serious vaccine-preventable disease. Environments with the same group of people who come into close contact with each other numerous times a day will enable faster and more comprehensive transmission of the virus to all occupants (workers and residents) than other more open settings.

6. The Social Care Working Group of SAGE has advised that an uptake rate of 80% in staff and 90% in residents in each individual care home setting would be needed to provide a minimum level of protection against outbreaks of COVID-19. This is for a single dose against the current dominating variant. These rates may be lower after a second dose, but the emergence of new variants may increase these levels, so estimates of the minimum coverage level can vary.

7. The rollout of the COVID-19 vaccination to older adult care homes has been impressive thanks to leadership across the NHS, the social care sector, and local government. As of 4 April 2021, 94.1% of all eligible people living in older adult care homes in England have received at least their first vaccination. As of 4 April 2021, 78.9% of all eligible workers in all older adult care homes had also received at least their first vaccination. While vaccination uptake rates are increasing slowly week on week, the overall figure of 78.9% for staff masks significant variation at a regional, local and individual care home level. As of 8 April 2021, 89 local authorities have a staff vaccination rate under 80%, including all 32 London Boroughs. 27 local authorities have a staff vaccination rate under 70%.

8. As a result, there are still a high number of older adult care homes which are not yet achieving the level of protection needed as advised by SAGE to reduce the risk of outbreak. Therefore, there remains a strong case for introducing a new requirement in order to make very high-risk environments as safe from the devastating effects of COVID-19 as possible.

What the government has done to encourage uptake

9. On 13 February 2021, we published the UK COVID-19 vaccines delivery plan, setting out the significant programme of work underway to drive vaccine uptake, including actions to improve access and to address the concerns of those who may be hesitant to receive the vaccine. We are also delivering a targeted programme of work to support vaccine uptake among adult social care staff and care home staff specifically, working with national and local stakeholders, including care home managers.

10. We have been working to make the vaccination accessible to people living and working in care homes – vaccination teams have visited care homes to offer vaccination directly. NHS England is running a minimum four-visit schedule for each older adult care home. For those workers who may not have been present when the vaccination team visited the home, access via other vaccination services has been available. We also opened the National Booking Service for 7 weeks so that frontline social care workers could book their own appointments. From 1 April, care home workers can arrange vaccination directly through their GP.

11. In order to address any questions and concerns among care home workers (and the wider adult social care workforce), we have delivered an extensive communications programme. This includes:

  • bespoke communications materials (posters, videos, leaflets, and shareable social media assets) shared across our CARE App, weekly newsletter, and adult social care and Department of Health and Social Care social channels

  • a paid advertising campaign targeting social care workers with digital advertising to build vaccine confidence and encourage booking on the National Booking Service

  • a stakeholder toolkit (Q&As, guidance and communications materials) which is updated weekly

  • positive messaging using influencers, leaders and care home workers who have already been vaccinated to boost confidence and tackle misinformation

  • content in different languages and briefings with different faith groups who have expressed interest in co-creating vaccine content and acting as ambassadors

12. We continue to work with stakeholders to identify further actions at a local, regional and national level to increase vaccine uptake. As part of this, we are targeting support to older adult care homes where vaccine uptake is low, such as in London. As of 4 April 2021, vaccine uptake among eligible workers in older adult care homes in London is 67.8%, compared to 82.4% in the South West. All of this is supplemented by work locally, by employers, local authorities, public health teams and others.

13. Despite these efforts, vaccine uptake amongst care home workers is not consistently at the level we know from SAGE advice is needed to minimise the risk of outbreak. It is imperative that together we now take every step necessary to reduce the risk of spreading the virus to those most at risk from COVID-19 and those who care for them. We must protect people living in care homes, and we must protect the workforce who perform such a vital role. Vaccination is a safe, effective way of preventing the spread of COVID-19. It is right that the government acts now to ensure that those deployed in older adult care homes are vaccinated to protect everyone in these settings.

Policy intention

14. We are proposing to amend regulations to require older adult care home providers to deploy only those workers who have received their COVID-19 vaccination in line with government guidance. This will not include those who can provide evidence of a medical exemption from COVID-19 vaccination. We also intend to amend the Code of Practice on the prevention and control of infections to explain the requirement. We are consulting on this policy and whether it should be extended to include other professionals who visit the care home, for example NHS workers providing close personal care to people living in the care home.

15. There are many other settings across adult social care and health, where people most at risk from COVID-19 are being cared for in high risk, closed settings. We will keep this policy under review on a continuing basis and consider whether in due course it is necessary to extend the policy to other parts of the adult social care and health sectors.

Proposed legislative change

16. We are planning to implement this policy through an amendment to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We propose to insert the requirement as a new provision in the fundamental standards in Part 3 of the Regulations, most likely into regulation 12 (which deals with safe care and treatment) as a supplement to regulation 12(2)(h), which requires that, as part of providing safe care and treatment, providers must assess the risk of, and prevent, detect and control the spread of, infections, including those that are healthcare associated. We will also be amending the Code of Practice on Infection Prevention and Control and its associated guidance, which is issued by the Secretary of State under section 21 of the Health and Social Care Act 2008 and to which providers must have regard when complying with their obligations under regulation 12 of the Regulations. Draft amendments to the Code of Practice have been published alongside this consultation (see Annex A).

17. Due to the importance of this issue, we intend to change the law quickly. It is our current intention for workers in older adult care homes to be required to keep their COVID-19 vaccination status up to date. This will be kept under review.

How do you feel about the proposed requirement for workers in older adult care homes to have a COVID-19 vaccination?

  • Supportive
  • Rather supportive
  • Neither supportive nor unsupportive
  • Slightly unsupportive
  • Not supportive
  • I don’t know
  • Not applicable

Please provide details to support your answer.

Older adult care homes

18. The proposed regulations would apply to any care home which has at least one person over the age of 65 living in their home in England and which is registered with the Care Quality Commission. This is estimated to be approximately 10,000 care homes.

Do you agree with using this definition to determine which care homes this regulation would apply to?

  • Yes
  • No
  • I don’t know
  • Not applicable

What concerns do you have about this definition?

19. The SAGE Social Care Working Group has advised that it is reasonable to proceed with care homes for older adults as a setting where requirement for vaccination may be appropriate. Care homes for older people have a population with a median age of over 80, with multiple co-morbidities. Some people living in care homes may have dementia and neurological and behavioural issues which impair their ability to follow infection control practices. In these closed settings, workers may provide care for, or have significant contact with, multiple residents as well as other workers. This level of interaction can lead to effective transmission of COVID-19 (and other infectious diseases) with severe outcomes for some people. Current estimates of case fatality ratio are about 20% – almost double that of individuals of similar age outside of care home settings. Vaccination is expected to significantly mitigate against severe outcomes.

Do you have any concerns about the proposal to limit this policy to older adult care homes?

  • Yes
  • No
  • I don’t know

Please explain your answer.

Persons requiring vaccination

20. It is our intention that the requirement to be vaccinated applies to all staff deployed in a care home supporting at least one older adult over the age of 65. This will ensure that vaccination coverage protects individual workers and people living in care homes and protects against the risk of outbreaks in the care home. This in line with advice from the SAGE Social Care Working Group.

21. This would include all workers employed directly by the care home or care home provider (on a full-time or part-time basis), those employed by an agency and deployed by the care home, and volunteers deployed in the care home. It would include those providing direct care and those working in care homes doing other roles, such as cleaners and kitchen staff. This is consistent with our approach to COVID-19 testing in care homes.

22. There is further consideration needed about whether we extend the requirement to include to those people who come to the care home to provide professional services, or other care and support. Arguably, this policy should extend to visiting professionals, in particular those who provide close personal care, such as health and care workers. It could also include hairdressers or visiting faith leaders. We are also carefully considering the situation of ‘essential care givers’ – those friends or family who have agreed with the care home that they will visit regularly and provide personal care. We understand that there are key considerations here for the range of people who may come into care homes and welcome your views in the consultation questions below.

23. We do not intend to extend this policy to friends and family members who visit people living in care homes – other than essential care givers, where we are considering carefully what approach is best. The SAGE Social Care Working Group has advised there is a balance to be struck between the risk of a loved one visiting and transmitting virus, against the wellbeing benefits to those who live in a care home. We would of course encourage friends and family members who are visiting the care home to access vaccination as soon as they are able however, as long as visitors carefully follow the advice in our guidance, we do not think it necessary to extend the requirement to family visitors. We welcome your views on this proposal in the question below.

Which people working or visiting in an older adult care home should be covered by the scope of the policy?

  • Only paid staff deployed in the care home

    • Yes
    • No
    • No opinion
  • Staff working for the care home provider who work in a separate building but may visit the care home occasionally (for example staff working in an off-site office)

    • Yes
    • No
    • No opinion
  • Health professionals who visit the care home regularly and provide close personal care to people living in the care home

    • Yes
    • No
    • No opinion
  • Other professionals who provide close personal care to people living in the care home, for example, hairdressers

    • Yes
    • No
    • No opinion
  • All professionals who enter a care home regardless of their role, for example, electrician, plumber, art therapist, music therapist

    • Yes
    • No
    • No opinion
  • Friends or family members designated as ‘essential carers’ who visit regularly and provide close personal care

    • Yes
    • No
    • No opinion
  • All friends and family who may visit

    • Yes
    • No
    • No opinion
  • Volunteers

    • Yes
    • No
    • No opinion
  • Other (please specify)

Exemptions

24. There will be a small number of people where the clinical advice is that the COVID-19 vaccination is not suitable for them. We will ensure that the regulations allow for exemptions on medical grounds. The regulations will be drafted in line with the Green Book on Immunisation against infectious disease (COVID-19: the green book, chapter 14a) and The Joint Committee of Vaccination and Immunisation (JCVI) which reflect clinical advice. Individuals will be exempt from the requirement if they have an allergy or condition that the Green Book lists (Chapter 14a, page 16) as a reason not to administer a vaccine, for example prior allergic reaction to a component of the vaccine, including polyethylene glycol (PEG). Some individuals have an allergy or condition where the Green Book or the JCVI advises seeking medical advice, before proceeding with vaccination, where a professional medical opinion should be sought on whether the individual should be exempt. Both nationally and internationally, no concerning safety signals have been identified so far in relation to the vaccination of women who are pregnant. JCVI is continuing to review data on the risks and benefit of vaccination for women without significant underlying health conditions who are pregnant. As evidence becomes available, it will be reviewed, and advice offered as appropriate.

25. The government is considering the least burdensome way for people to demonstrate to their employers that they are medically exempt from vaccination.

26. The policy will be reviewed if significant obstacles would prevent eligible workers from accessing vaccination in a timely and accessible way, such as due to vaccine supply issues or changes in national clinical guidance. For example, this would mean that if supply issues make it impossible for a member of staff to access a vaccination within a reasonable travelling distance, the requirement will not apply to that individual until the supply issue is resolved.

27. The government will follow JCVI advice, which sets out that, as a precaution, it is preferable for under-30s with no underlying conditions to be offered an alternative to the Oxford/AstraZeneca vaccine where available.

Do you agree or disagree with the groups of people who would be exempt from this requirement?

  • Strongly agree
  • Tend to agree
  • Neither agree nor disagree
  • Tend to disagree
  • Strongly disagree
  • I don’t know
  • Not applicable

Who else should be exempt from this requirement?

Implementation

28. Care home managers are ultimately responsible for the safety of people living in their care. Under the proposed change to regulations, it would therefore be their responsibility to check evidence that workers deployed in the home are vaccinated, or medically exempt from vaccination. This means that workers would need to provide evidence to the manager that they have been vaccinated.

29. The government is carefully considering the best way for people to prove that they have been vaccinated to their employer. This may involve, for example, showing vaccination status on a mobile phone app.

This question is specific to care home managers as we want to understand how care home managers would respond to staff that aren’t vaccinated.

Your staff would need to be able to show that they had been vaccinated. How would you prefer that they do this?

  • Mobile app
  • Written self-declaration
  • Verbal confirmation
  • I don’t know
  • Other (please specify)
  • Not applicable

This question is specific to staff in care homes as they focus on the practicalities of proving vaccination status.

You would need to be able to show you have been vaccinated. How would you prefer to do this?

  • Mobile app
  • Written self-declaration
  • Verbal confirmation
  • I don’t know
  • Other (please specify)
  • Not applicable

These questions are specific to local authorities and NHS partners as they focus on their ability to commission services.

Do you have any concerns about the impact of the proposed requirement on your ability to commission services?

  • Yes
  • No
  • I don’t know
  • Not applicable

What concerns do you have about the impact of the proposed requirement on your ability to commission services?

30. The government is considering what would be an appropriate grace period for new and existing care home workers before they are required to be vaccinated.

31. It is our expectation that care home managers would keep a record of vaccinations as part of their staff employment and occupational health records.

How easy will this policy be for managers in older adult care homes to implement?

  • Very easy
  • Quite easy
  • Neither easy nor difficult
  • Quite difficult
  • Very difficult
  • I don’t know
  • Not applicable

Please provide details to support your answer.

The role of the Care Quality Commission

32. It is our intention that this requirement would form part of the Fundamental Standards (set out in The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014) and would be monitored and enforced in appropriate cases, by the Care Quality Commission (CQC). It would apply to any care home that has any person over the age of 65 living there. Reported vaccination rates would form part of a suite of information CQC considers when determining which settings to inspect.

33. At time of registration and when inspected, care home managers would have to provide evidence that their workers are up to date with vaccination of an MHRA-approved COVID-19 vaccine.

34. In case of non-compliance with the legislation, CQC would take a risk-based and proportionate approach to enforcement, looking at all the evidence identified and whether the public interest test is met, in line with its enforcement policy. CQC has civil enforcement powers and in the most serious of cases, criminal enforcement against the provider or registered manager may be appropriate.

35. Civil enforcement options available to CQC include issuing: a warning notice, issuing a notice of proposal/decision to impose, vary or remove registration conditions, issuing a notice of proposal/decision to suspend or cancel registration, making an application to court for immediate cancellation of registration where there is serious risk to a person’s life, health or well-being and issuing an urgent notice of decision to suspend or vary conditions of registration where there is risk of harm to a person.

36. Regulation 12 imposes a requirement on providers and registered managers to provide safe care and treatment. This includes a requirement for the provider and registered manager to assess the risk of, and prevent, detect and control “the spread of, infections, including those that are health care associated”. This is supplemented by the Secretary of State’s IPC Code issued under s.21 of the Health and Social Care Act 2008. Where a breach of regulation 12 results in avoidable harm or a significant risk of avoidable harm to a service user, the provider or registered manager may be guilty of a criminal offence, and the CQC will look at whether to take criminal enforcement action. The maximum fixed penalty notice is £2,000 or £4,000, in respect of an offence committed by a registered manager or provider respectively.

Impact and implications of the policy

37. Our initial Public Sector Equality Duty (PSED) analysis indicates that making vaccination a condition of deployment in older adult care homes could have a more significant impact on certain groups. In particular, the adult social care workforce has a high proportion of women and people from black, Asian and minority ethnic communities. There is some evidence to suggest these groups may be more hesitant about vaccination more generally and the COVID-19 vaccine specifically given it is a new vaccine. There continues to be a significant programme of work to address these concerns as part of the ongoing work to support uptake specifically within the adult social care workforce and the wider population. We are very interested to understand what more we can do to ensure these groups, and any other, would not be differentially impacted by this new policy and how we can manage this to achieve our ambition to protect all those deployed and being supported in care home settings.

Are there particular groups of people, such as those with protected characteristics, who would particularly benefit from this policy?

  • Yes
  • No
  • I don’t know
  • Not applicable

Which particular groups might be positively impacted and why?

Are there particular groups of people, such as those with protected characteristics, who would be particularly negatively affected by this policy?

  • Yes
  • No
  • I don’t know
  • Not applicable

Which particular groups might be negatively impacted and why?
What could we do to make sure they are not negatively impacted?

38. We intend to publish our Public Sector Equality Assessment as part of the response to this consultation and will carefully track the impact of the policy on vaccine uptake, should it be implemented.

39. Retaining a skilled, compassionate and caring workforce, keeping the workforce and the people they care for safe, and making working in adult social care an attractive career choice is at the heart of this policy intent. We recognise the sacrifices that have been made in the face of the pandemic by those working in care homes over the last year. We believe that introducing this policy reflects the need to move at pace and with purpose to avoid the risk of future avoidable outbreaks in care homes. We will continue to support care home providers and individual members of staff to access COVID-19 vaccination and build on the progress that has already been made. This will include access to 1 to 1 support from a trusted person for those who have any concerns about vaccination and continuing to ensure, through the NHS vaccination programme, that access to vaccination is as easy as possible on an ongoing basis.

40. It is recognised that some people may choose not to be vaccinated, even if the vaccination is clinically appropriate for them. In these circumstances they will no longer be able to be deployed in a care home setting and providers will need to manage this in a way which does not destabilise the provision of safe, high quality care. We are asking a question in this consultation about the possible impact on staffing levels, if workers chose to leave the care home workforce rather than be vaccinated. This may be a particular issue in some local areas where uptake is lower.

These questions are specific to care homes managers as we want to understand how care home managers would respond to staff that aren’t vaccinated.

How do you anticipate you would respond to the requirement, thinking about staff who are not vaccinated?

  • Redeploy unvaccinated staff
  • Cease employment for unvaccinated staff
  • Other (please specify)
  • Not applicable

Do you have any concerns about the impact of the policy on the ability of older adult care homes to maintain a safe service?

  • Yes
  • No
  • I don’t know
  • Not applicable

Which of the following are concerns that you have about the impact of the policy on the ability of older adult care homes to maintain a safe service? (tick all that apply)

  • Some staff may refuse the vaccine and leave their current job
  • Some staff may leave in protest at the policy, if this conflicts with their personal beliefs
  • Remaining staff may resent the requirement, reducing morale
  • Staff may seek to challenge care homes in court
  • The impact it could have on other measures affecting staff, such as reducing movement between health and care settings
  • The supply of alternative trained staffing available
  • The cost of short-term staff cover
  • The cost of recruiting new permanent staff
  • The time it will take to recruit new permanent staff
  • Other (please specify)

Please share any evidence and your sense of the scale of these impacts here:

  • Minimal impact
  • Moderate impact
  • Severe impact

Please provide details to support your answer.

How do you think we can minimise the impact of this new policy on the workforce? (tick all that apply)

  • Ease of access to vaccination
  • Specific funding to cover any costs associated with vaccination for example travel, time, costs of side effects
  • Access to up to date information
  • Support from local authority vaccination champions
  • Support from clinical leads linked to care home
  • Other (please specify)

Do you think this new policy could cause any conflict with other statutory requirements that care homes must meet?

  • Yes
  • No
  • I don’t know
  • Not applicable

Please give further detail on other statutory requirements that this new policy could conflict with.

41. During the consultation period, we intend to discuss directly with employers the anticipated impact on individuals and the employment law consequences. If the policy is implemented, we will consider publishing operational guidance for care home managers setting out implications for managers and members of staff.

Annex A: proposed addition to the code of practice – criterion 10

Registered providers should ensure policies and procedures are in place with regard to COVID-19 immunisation status of all staff such that:

All eligible staff in care homes with one or more residents aged 65 and over have had their COVID-19 vaccinations. This includes all staff employed directly by the care home provider, those employed by an agency, and volunteers deployed in the care home. It also includes those providing direct care and those undertaking ancillary roles such as cleaners and kitchen staff.

The provider will demonstrate that all eligible staff deployed in the care home have received the required doses of an MHRA approved COVID-19 vaccines within the specified grace period, in line with regulation 12,[footnote 2] which is kept securely by the registered manager (or equivalent person) in staff files. This applies to existing and new staff.

There is a record of medical exemption for staff who are unable to receive a COVID-19 vaccine due to health reasons (as per the Green Book, JCVI guidance and medical advice).

For staff who are unable to be vaccinated due to health reasons, registered managers (or the equivalent person) will have completed risk assessments and taken appropriate actions to mitigate risks.

The eligibility for immunisation of staff is regularly reviewed in line with Regulation 12.

There is appropriate education of staff about the requirement, and the benefits for them as individuals and for people using their service.

Staff are provided with the appropriate support to access vaccination.

  1. All data referenced in this consultation is England only unless otherwise specified. 

  2. Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires care and treatment to be provided in a safe way for service users. This includes an obligation on the registered person to assess the risk of, and prevent, detect and control the spread of infections, including those that are health care associated (regulation 12(2)(h)). The proposal is to amend regulation 12 to include the vaccination requirements described in this consultation document. CQC have the power to bring a prosecution against a provider who fails to meet regulation 12, where this failure leads to avoidable harm, or the significant risk of such harm.