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))
the proper and safe management of medicines, (Reg 12(2)(g) (medicines management))
Regulation 12 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.
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, safe care starts with a proper, person-specific risk assessment using current national travel health guidance, advice that is tailored to the traveller and their trip, and a clear record of what was assessed, advised, given and declined.
3. Purpose
A safe travel health consultation is built on a proper risk assessment. The right advice depends on where the traveller is going, what they will do there, and their own health. This policy sets out how the Service assesses each traveller, gives advice based on current national guidance, and records it, so that the vaccines, antimalarials and health advice given are right for that person and that trip.
The Service must verify this policy against current national travel health guidance (TravelHealthPro / NaTHNaC and the Green Book) before adoption.
4. Scope
This policy applies to:
- every traveller the Service advises
- the consultation, the advice given, and its record
- the nurses, pharmacists and doctors who carry out travel consultations
5. The risk assessment
For each traveller the Service assesses, using current country information:
- the destinations and the route, including stopovers
- the dates, the length of the trip and the time before departure
- the type of travel and activities (for example rural or remote travel, trekking at altitude, working in healthcare, contact with animals, freshwater exposure, adventure sports)
- the accommodation and likely food and water standards
- the traveller's own health: age, pregnancy or planned pregnancy, breastfeeding, long-term conditions, immune status and any immunosuppression, allergies, current medicines, and previous reactions to vaccines
- the traveller's vaccination history
The assessment is based on the country and clinical information current at the time of the consultation, because risk and recommendations change.
6. The advice given
From the risk assessment the Service advises on:
- recommended and required vaccinations, including which are a course needing time before travel
- malaria risk and, where needed, antimalarial options, bite avoidance, and the limits of any chemoprophylaxis
- food and water safety, travellers' diarrhoea, and what to carry
- insect-bite avoidance, sun protection, altitude, and accident and road-safety risks
- blood-borne and sexually transmitted infection risks where relevant to the trip
- what to do if they become unwell abroad, and the importance of travel insurance and, where relevant, a record of their vaccinations to carry
Advice is tailored to the person, not a generic destination handout.
7. Timing and incomplete courses
- the Service explains where a vaccine course needs to start well before departure, and what protection is realistic when there is little time
- where a traveller presents late, the Service gives the best available protection and is honest about the gaps
- a traveller who needs more than one visit is given a clear plan for the remaining doses
8. When the Service is not the right place
The Service is clear about the limits of what it offers. Where a traveller needs care beyond travel health (for example management of a complex condition before travel, or specialist advice for a particular risk), the Service says so and signposts the traveller to the right service rather than advising outside its competence.
9. Recording
The Service records, for each consultation: the risk assessment, the advice given, the vaccines and medicines provided (with batch numbers where given), the traveller's consent, and any advice declined. The record shows that a tailored assessment took place.
Operational controls to adapt
Roles and responsibilities
- Registered Manager: owns the consultation pathway, makes sure only competent staff provide travel-health advice, and reviews incidents, complaints and audit findings.
- Clinical lead: maintains the approved guidance sources, escalation route and consultation template, and reviews complex or high-risk cases.
- Travel-health clinician: completes the person-specific assessment, checks current country guidance, advises within competence and records decisions, consent and declined advice.
- Booking or administration team: gathers pre-consultation information, identifies late travel or complex needs, and books enough time for a safe consultation.
- Governance lead: tracks documentation gaps, late-presenting themes, declined advice, incidents and improvement actions.
Pre-travel consultation procedure
- Collect the itinerary before advice is given. Record destinations, route, stopovers, travel dates, departure date, trip length, accommodation, activities and remote or rural exposure.
- Assess the traveller, not only the destination. Check age, pregnancy or breastfeeding, immune status, long-term conditions, allergies, medicines, previous vaccine reactions and vaccine history.
- Use current country and clinical guidance. Record the guidance source and access date for vaccine, malaria, outbreak, certificate and health-risk advice.
- Match advice to the risk assessment. Record recommended vaccines, required vaccines, malaria prevention, bite avoidance, food and water advice, accident risk, insurance advice and when to seek help abroad.
- Explain limits and timing. Tell late presenters what protection is realistic, what cannot be completed before travel, and any follow-up dose or course plan.
- Record consent and declined advice. A traveller may decline advice, vaccine or medicine, but the record must show what was explained and what risk remains.
- Escalate complex cases. Immunosuppression, pregnancy, significant allergy, serious comorbidity, uncertain yellow fever suitability or advice outside competence is referred to the clinical lead or specialist source.
- Close the loop. Follow-up appointments, remaining doses, prescriptions, certificate needs and written information are given before the consultation is closed.
Records and register links
The consultation record should include:
- itinerary, route, stopovers, dates, trip length, accommodation and activities
- health history, medicines, allergies, immune status, pregnancy or breastfeeding and vaccine history
- guidance source used, country page or clinical guidance date, and any specialist advice sought
- risk assessment, vaccines recommended or required, vaccines given or declined, medicines supplied, malaria advice and non-vaccine advice
- consent, contraindications, precautions, declined advice, late-presenter limitations and follow-up plan
- written information supplied and how incomplete courses or booster reminders will be tracked
- linked incident, risk, complaint, medicines, safeguarding or improvement-action reference where the control failed
Missed risk assessments, advice outside competence, wrong destination advice, vaccine or medicine errors and repeated declined-advice documentation gaps are opened on the relevant register.
10. Training and competency
Clinicians carrying out travel consultations are trained and assessed as competent for travel health, keep up to date as guidance changes, and are refreshed on a stated cadence. The Service records who is competent and the next refresher date.
11. Audit cadence
The Service checks, on a stated cadence, that:
- consultations are based on a documented, person-specific risk assessment using current country information
- the advice, vaccines and medicines given match the assessment
- timing, incomplete courses and declined advice are recorded
- clinicians' travel health competence is current
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.
- TravelHealthPro (National Travel Health Network and Centre, NaTHNaC), country information and clinical guidance: https://travelhealthpro.org.uk/
- Immunisation against infectious disease (the Green Book): https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book
- Royal College of Nursing, competencies for travel health nursing: https://www.rcn.org.uk/
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12 (safe care and treatment): https://www.legislation.gov.uk/uksi/2014/2936/regulation/12
- CQC Regulation 12: Safe care and treatment
- CQC Fundamental Standards
- UKHSA Green Book and vaccine storage / cold-chain guidance (travel clinic vaccine storage)
- NaTHNaC Yellow Fever Vaccination Centre guidance; UKHSA (yellow fever)
- Resuscitation Council UK; the Green Book; emergency medicines and equipment guidance (anaphylaxis)
- NICE Patient Group Direction (PGD) guidance; Human Medicines Regulations 2012; Specialist Pharmacy Service (SPS) PGD guidance (PGDs and travel medicines)
- Relevant NICE guidance; MHRA safety alerts; NHS Patient Safety Alerts / CAS alerts
Related reading
- Related policy: Patient Group Directions and prescribing policy
- Related policy: Yellow fever vaccination centre and ICVP policy
- Related policy: Vaccine storage and cold chain policy
- Related policy: Anaphylaxis management policy
- Related policy: Consent policy
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, consultation procedure, risk-assessment records, register links and related reading. |
| v1 | 2026-06-10 | Verivius (sample) | Initial sample template, conformed to the Verivius policy standard. |
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.