Sample policy · Travel clinics

Anaphylaxis management policy (travel clinics)

Statutory anchor: Regulation 12 (safe care and treatment), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). The clinical primary for this policy is the Resuscitation Council UK emergency treatment of anaphylaxis guidance and the Green Book chapter on adverse reactions. Providers must check the live source before adopting specific clinical steps, medicine lists, dose schedules, forms or reporting processes. · primary source

1. What the regulation says

Care and treatment must be provided in a safe way for service users. (Reg 12(1) (the headline duty))

assessing the risks to the health and safety of service users of receiving the care or treatment, (Reg 12(2)(a) (risk assessment))

doing all that is reasonably practicable to mitigate any such risks, (Reg 12(2)(b) (risk mitigation))

ensuring that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely, (Reg 12(2)(c) (staff competence))

where equipment or medicines are supplied by the service provider, ensuring that there are sufficient quantities of these to ensure the safety of service users and to meet their needs, (Reg 12(2)(f) (sufficient equipment + medicines supply))

the proper and safe management of medicines, (Reg 12(2)(g) (medicines management))

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

Care and treatment must be provided in a safe way. The regulation lists the areas a provider must address, including risk assessment, risk mitigation, staff competence, safe premises, safe equipment, sufficient equipment and medicines, medicines safety, infection prevention and shared-care planning. Regulation 12 is central to CQC's safety expectations. For a travel clinic this means being ready to recognise and treat anaphylaxis: the right in-date adrenaline and kit, trained staff, and a clear plan to act fast.

3. Purpose

Any service that gives vaccines or injections must be ready to recognise and treat anaphylaxis, a rare but life-threatening allergic reaction that can happen within minutes. A travel clinic gives many injections, so it must have the right equipment, trained staff and a clear plan. This policy sets out how the Service prevents, recognises and treats anaphylaxis and learns from any event.

The Service must verify this policy against current Resuscitation Council UK anaphylaxis guidance and the Green Book chapter on adverse reactions before adoption.

4. Scope

This policy applies to:

5. Reducing the risk

6. Recognising anaphylaxis

Staff are trained to tell anaphylaxis apart from a simple faint. Anaphylaxis is a sudden reaction with airway, breathing or circulation problems, often with skin changes. A faint usually settles quickly when the person lies down. When in doubt, the Service treats it as anaphylaxis, because delay is the main cause of harm.

7. Immediate treatment

The Service follows the current Resuscitation Council UK anaphylaxis algorithm. In outline:

The Service confirms the exact doses and steps against the current Resuscitation Council UK guidance.

8. Equipment and medicines

9. After an event

Operational controls to adapt

Roles and responsibilities

Anaphylaxis response procedure

  1. Check readiness before clinics start. Confirm adrenaline, syringes, needles, oxygen where held, AED, dose aids, emergency contacts and the current algorithm are available wherever injections are given.
  2. Screen before vaccination. Check allergy history, previous vaccine reactions, relevant vaccine components and whether specialist advice is needed before proceeding.
  3. Observe and listen after vaccination. Tell the traveller what symptoms to report, keep them where staff can see or hear them for the stated observation period, and act on concerns promptly.
  4. Treat suspected anaphylaxis as an emergency. Use an ABCDE approach, call 999 early, position the person safely and give intramuscular adrenaline according to the current algorithm.
  5. Record times as the event unfolds. Capture symptom onset, observations, adrenaline time and dose, repeat dose decision, 999 call time, ambulance arrival and handover.
  6. Do not close the case at recovery on site. The person is transferred or referred for medical assessment and observation as the live guidance requires.
  7. Recover the system after the event. Restock the kit, quarantine any medicine or vaccine involved where needed, complete the clinical record, Yellow Card report, incident record and debrief.
  8. Review learning. Repeated kit gaps, delayed response, unclear role allocation or documentation gaps are opened on the risk or improvement-actions register.

Records and register links

The anaphylaxis readiness and event record should include:

Missing or expired adrenaline, delayed treatment, unclear records, overdue training and repeated drill failures are logged as incidents or risks, not left as informal reminders.

10. Training and drills

11. Audit cadence

The Service checks, on a stated cadence, that:

The Registered Manager and the clinical lead review the results and record the improvement actions that follow.

12. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

Related reading

13. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

14. Document control

Version Date Author Changes
v1.1 2026-07-14 Verivius (sample) Added role ownership, anaphylaxis response procedure, readiness records, register links and related reading.
v1 2026-06-10 Verivius (sample) Conformed the existing draft to the Verivius policy standard: added statutory anchor, verbatim Regulation 12 quotes, plain-English summary, sources and further reading, and document control. All original sections and source URLs preserved.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

A travel clinic is one of the few settings that gives several injections to a well person in a single appointment, often in a small high-street room staffed by one clinician and a receptionist, and often to someone who is flying within days. That is what makes anaphylaxis here distinctive: the reaction arrives in someone who walked in healthy, the adrenaline is a medicine the team may never have had to use, and where three or four vaccines went in at once the record is the only way anyone will later work out which component that traveller must avoid. Real clock times, and a note of what the traveller was told before they left, are what turn a frightening few minutes into something the hospital and the next clinician can act on. It matters for the person's own travel too, because vague advice to avoid vaccines in future can strand someone who in fact needed only one component avoided. Kept properly, the same records let the clinical lead spot drift, an expired ampoule, a delayed injection, a drill that never happened, while it is still a near miss rather than a harm.

  1. In-date adrenaline and the anaphylaxis kit are immediately available wherever injections are actually given, with the checks recorded, not held centrally or checked without a written trail; missing or expired adrenaline is logged as an incident, not left as an informal reminder.

    Strong evidence: Section 8 and the readiness record fields emergency equipment and medicine check date, checker, batch, expiry, missing items and corrective action; audit cadence line that the anaphylaxis kit and adrenaline are present, in date and checked wherever injections are given.

    Weak evidence: Weak evidence is a single "emergency kit present" tick on a general premises checklist, with no batch number, no expiry date and no named checker, while the adrenaline sits in a cupboard in the office and injections are given in two other rooms. It is also weak where an expired ampoule is quietly swapped and the swap appears nowhere, so nobody can say how long the clinic ran without usable adrenaline at the point where the needle actually goes in.

    What the regulator expects to see. Not a law in itself, but CQC judges you against it, so an inspector will look for it and expect a reason where you depart from it.

  2. An anaphylaxis event is documented with a real timeline (symptom onset, intramuscular adrenaline time and dose, the repeat-dose decision, the 999 call time and ambulance handover), because delay is the main cause of harm and the timeline is what shows how quickly the person was actually treated.

    Strong evidence: Section 7 and procedure step 5, with the event record fields event timeline, symptoms, observations, treatment, adrenaline dose, route and response, and 999 call time and ambulance handover.

    Weak evidence: Weak evidence is a note written after the ambulance has left that reads "suspected anaphylaxis, adrenaline given, 999 called, transferred", with no clock times anywhere. If nobody can say how many minutes passed between the first symptom and the intramuscular injection, or whether a repeat dose was considered and why it was or was not given, the record cannot show that treatment was prompt.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  3. The person is referred or transferred to hospital for observation and the case is not closed at apparent recovery on site, because a reaction can return after it first settles.

    Strong evidence: Section 9 and procedure step 6 (do not close the case at recovery on site), with the record field transfer or referral advice and follow-up outcome where known.

    Weak evidence: Weak evidence is an entry that closes with "recovered fully, went home" or "advised to contact GP if unwell", with no record of transfer or referral and no follow-up outcome. It is also weak where the traveller declined to go to hospital and the record does not show what they were told about the reaction returning after it first settled, or who stayed with them.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  4. After an event the record shows the MHRA (Medicines and Healthcare products Regulatory Agency) Yellow Card report was made, and that the duty-of-candour threshold and the statutory-notification threshold were each assessed and each decision recorded rather than left to informal judgement. The three are separate and independent: a Yellow Card report to the MHRA is not a notification to CQC, and the duty of candour is owed to the person, so being open with them is not discharged by notifying CQC and is owed even where no statutory notification applies.

    Strong evidence: Section 9 and the record fields Yellow Card report, duty-of-candour decision, statutory-notification decision, debrief and improvement action.

    Weak evidence: Weak evidence is an incident form with "duty of candour: not applicable" ticked and no reason recorded, a Yellow Card entry marked "to be done" that is never confirmed as sent, and the three decisions collapsed into one line so nobody can see which threshold was actually considered. It is weaker still where the team assumes that notifying CQC discharges the openness owed to the traveller, so no apology or explanation to the person is recorded at all.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  5. Everyone who injects, and the staff who would assist, are trained in anaphylaxis recognition and resuscitation and are in date, evidenced by drill records, not a one-off induction sign-off.

    Strong evidence: Section 10 and the record fields staff anaphylaxis, life-support and drill records including refresher dates; audit cadence line that staff who inject are trained in anaphylaxis and resuscitation and are in date.

    Weak evidence: Weak evidence is a training matrix showing "anaphylaxis: yes" against every name with no completion date and no refresher date, resting on an induction certificate from several years ago. It is weaker still where the bank or locum clinician who injects on Saturdays is not on the matrix at all, so nothing shows that the person holding the syringe was competent to treat the reaction it caused. Drills are described as happening but no record of one can be produced against the cadence the Service has set itself.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  6. Allergy and previous-reaction questions are asked before vaccination, and the traveller is offered the post-vaccination observation period the Service has stated, so an early reaction can be seen and treated.

    Strong evidence: Section 5 and the record field allergy and previous-reaction questions asked before vaccination; audit cadence line that allergy histories are checked before vaccination and post-vaccination waiting is offered.

    Weak evidence: Weak evidence is a consent form with a pre-ticked "no known allergies" box and identical wording on every record, so it is impossible to tell whether the allergy and previous-reaction questions were ever asked of this traveller. It is also weak where the Service has never stated an observation period at all, or has stated one and nothing in the record shows whether the traveller was asked to wait, was told which symptoms to report, or simply left straight after the injection.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

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Last verified 20 July 2026

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Last reviewed 10 June 2026