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CQC to inspect practices on five new points relating to mandatory Covid vaccination

by Caitlin Tilley
8 December 2021

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CQC will inspect GP practices on compliance with five different new points related to mandatory staff Covid vaccination from April.

Mandatory Covid vaccination of frontline staff, which will come into force from 1 April subject to parliamentary approval, will be ‘monitored and enforced by CQC’, NHS England said in new guidance.

The guidance, issued yesterday, also included a check list for what steps GP practices should now take to prepare for the mandate to come into effect; as well as a tool kit for one-to-one conversations to encourage staff to have their Covid vaccination.

With regards to regulation, the document said GP practices will be expected to ‘keep a record of vaccinations as part of their staff employment or occupational health records’.

GP practices will need to prove to CQC inspectors that:

  • They have systems in place to ensure that they can comply with the requirements of the regulations and that they can monitor compliance.
  • There is a record to confirm that satisfactory evidence has been provided. This record must be kept securely by the registered person in compliance with the UKGDPR and the Data Protection Act 2018.
  • They have systems in place to review whether they need further evidence in relation to vaccination or exemption status of the people they employ or otherwise engage for the purposes of the provision of the regulated activity, carry out those reviews and secure such further evidence.
  • There is appropriate information and access to advice/guidance about vaccines and the requirements of the regulations available to all workers, and that individuals receive support in connection with the vaccine.
  • Workers are provided with the appropriate support to access vaccination.

It follows the Government’s announcement on 9 November that Covid-19 vaccination will be a ‘condition of deployment’ for all health sector workers in direct contact with patients from April next year.

Unvaccinated staff must get their first Covid jab by 3 February 2022 so they can receive their second dose by the 31 March 2022 deadline, NHS England’s guidance said.

Earlier this year, the Government made a similar mandate for all care home staff, which came into force in November.

And GP practices should now begin to prepare by determining which roles in their practice are likely to fall under the new regulations.

They also need to update privacy notices regarding data collections, and should begin one-to-one conversations with staff to ‘convert vaccine hesitancy into vaccine uptake’.

GP practices should then begin to record vaccination status of all staff that are ‘in scope’ of the mandate.

They also have to ensure temporary workers and trainees in patient-facing roles are vaccinated, the guidance added.

Practices are encouraged to consider redeploying unvaccinated staff, but the guidance acknowledges opportunities for redeployment ‘may be challenging’ for smaller organisations such as GP practices.

The guidance also cautioned not to formalise redeployments until the mandate is approved in Parliament – expected on 6 January.

NHS England said the new guidance – which spans 30 pages – can be ‘generally applied’ to GP practices, but added that as independent contractors they may also wish to ‘seek individual legal advice’ on the vaccine mandate.

The news comes as routine CQC inspections are currently paused to free up GP time, although targeted inspections – including with regards to patient access – are still going ahead.

How to manage exemptions

GP practice employees who cannot be vaccinated for medical reasons must prove this with a medical exemption notice. They must also be referred to occupational health for ‘advice and recommendations’.

Meanwhile, pregnant employees can use their MATB1 certificate as proof of exemption status up until 16 weeks after giving birth – despite guidance strongly recommending pregnant women get vaccinated against Covid.

If a worker is exempt due to partaking in a clinical trial, they must provide their workplace with evidence ‘in writing’.

While the regulations do not include boosters, it said employers are ‘advised to provide supportive advice to workers to encourage uptake’.

GP practices may continue to employ workers exempt from vaccination, but managers should proactively ensure ‘the health and safety of both the individual, other workers, patients and visitors’.

They must also update current risk assessments to determine the ‘potential risk of Covid-19 spread caused by unvaccinated (but exempt) workers’ and the ‘level of risk of exposure to the individual, other workers, patients and visitors’.

Other measures may be necessary to mitigate the risk, including reviewing PPE use, regular lateral flow testing, working from home, sufficient ventilation in the practice, cleaning regimes and hand-washing.

Source: NHS England

How to conduct one-to-one conversations with vaccine-hesitant staff:

  • Ensuring the individual is aware of the regulations and advising them of the impact of the regulations on their role. 
  • Discussing any individual circumstances that may currently be stopping them from getting the Covid-19 vaccination with understanding and compassion. 
  • If the individual advises that they are medically exempt, please signpost them to obtaining evidence of clinical exemption. 
  • Addressing concerns and vaccine hesitancy.
  • Providing details of access to expert clinical advice from clinicians locally wherever possible. 
  • Signposting the employee to support services (including health and wellbeing and occupational health) and Covid-19 vaccination information resources from NHS England and the Department of Health and Social Care. 
  • Encouraging the employee to have further conversations with their own GP or trusted healthcare professional if they have any further questions around vaccination. A detailed record of informal conversations should be maintained.

Source: NHS England

This story was initially published on our sister title Pulse.