Chaperone policy

At this organisation, all patients will routinely be offered a chaperone, ideally at the time of booking an appointment. It is a requirement that, when necessary, chaperones are provided to protect and safeguard both patients and clinicians during intimate examinations or procedures. This policy adheres to the guidance detailed in CQC GP mythbuster 15: Chaperones and NHS England’s Improving chaperoning practice in the NHS: key principles and guidance. 

To raise awareness, the chaperone policy will be clearly advertised. At this organisation, a chaperone poster is displayed in the waiting area, all clinical areas and annotated in the organisation leaflet as well as on the organisation website. 

In accordance with the Equality Act 2010, we have considered how provisions within this policy might impact on different groups and individuals. This document and any procedures contained within it are non-contractual, which means they may be modified or withdrawn at any time. They apply to all employees and contractors working for the organisation.  

At this organisation, it is policy that any member of the team can act as a chaperone. However, they must have undertaken chaperone training as detailed in CQC GP mythbuster 15. Additionally, all staff must complete chaperone awareness training which covers the role of the chaperone.  

The General Medical Council (GMC) Intimate examinations and chaperones guidance explains that the patient should be given the option of having an impartial observer (a chaperone) present whenever possible.  

As per the GMC guidance, relatives or friends of the patient are not considered to be an impartial observer so would not usually be a suitable chaperone but staff at this organisation should comply with a reasonable request to have such a person present in addition to the chaperone. 

The GMC guidance also provides detailed guidance on what the clinician should do before and during the examination, including adhering to the GMC Decision making and consent guidance. When a chaperone is present, the details of the chaperone must be recorded in the patient’s clinical record. 

Staff must demonstrate cultural sensitivity and respect each patient’s individual values regarding privacy, dignity and intimacy. When offering or providing a chaperone, staff should consider the patient’s preferences in relation to choice of chaperone, which might include considerations relating to sex, religious beliefs or other personal circumstances. 

Staff should also identify where patients may have additional needs, such as communication difficulties or learning disabilities, and make reasonable adjustments to ensure they understand the offer and feel supported. This may include using accessible information, involving carers or advocates, or allowing extra time for discussion. 

The purpose of the examination and the role of the chaperone must be communicated using culturally appropriate and respectful language. 

Staff at this organisation acting as a chaperone are to adhere to the guidance referenced at 2.2. CQC GP mythbuster 15: Chaperones advises that for most patients and procedures, respect, explanation, consent and privacy are all that are needed. These take precedence over the need for a chaperone. A chaperone does not remove the need for adequate explanation and courtesy. Neither can a chaperone provide full assurance that the procedure or examination is conducted appropriately. 

The GMC further advises that if either the clinician or the patient does not want the examination to go ahead without a chaperone present, or if either is uncomfortable with the choice of chaperone, the clinician may offer to delay the examination until a later date when a suitable chaperone will be available providing the delay would not adversely affect the patient’s health. 

If the clinician does not want to proceed with the examination without a chaperone but the patient has refused a chaperone, the clinician must clearly explain why they want a chaperone to be present. The GMC states that ultimately the patient’s clinical needs must take precedence. The clinician may wish to consider referring the patient to a colleague who would be willing to examine them without a chaperone providing a delay would not adversely affect the patient’s health.  

Any discussion about chaperones and the outcome should be recorded in the patient’s medical record, and in particular: 

Clinical staff who undertake a chaperone role at this organisation will already have had a DBS check. CQC GP mythbuster 15: Chaperones states that non-clinical staff who carry out chaperone duties may need a DBS check. This is due to the nature of chaperoning duties and the level of patient contact. Should the organisation decide not to carry out a DBS check for any non-clinical staff, then a clear rationale for this decision must be given including an appropriate risk assessment.  

Image requested templates send using accurx detail that intimate photographs should not be submitted. If the promblem the patient wishes to consult about affects an itimate area, a face-to-face examination should be conducted whereever possible.  

While it is widely accepted that many intimate examinations will not be suitable for a video consultation, should such a consultation be agreed, staff at this organisation are to adhere to the guidance detailed in CQC GP mythbuster 15. 

NHS England guidance states that patients should be offered a chaperone in advance of a home visit appointment. This will enable a chaperone to accompany the clinician during the visit. When this is not possible, clinicians must ensure there is clear communication and thorough documentation explaining why the examination proceeded without a chaperone being present and that this was agreed with the patient. 

NHS England guidance explains that when any patient is unable to make an informed decision, the healthcare professional must use their clinical judgement and be able to justify their course of action. This organisation will ensure any necessary reasonable adjustments are made for vulnerable patients.  

Any intimate examination on children and young people under 18 years should be carried out in the presence of a formal chaperone. A parent, carer or someone known and trusted by the child may also be present during the examination or procedure to provide reassurance. Parents or guardians must receive an appropriate explanation of the procedure to provide informed consent when the young person is unable to do so themselves. 

If a chaperone was not requested at the time of booking the appointment, the clinician will offer the patient a chaperone explaining the requirements: 

There may be, on occasion, a need to ensure that appropriate measures are in place to escort visitors and guests including VIPs. On such occasions, this organisation will follow the recommendations outlined in the Lampard Report (2015). 

If media interest is likely, the Practice Manager is to inform the local ICB, requesting that the communication team provides guidance and/or support where necessary. 

12. Escalation and raising concerns 

All organisations should have clear routes in place for raising concerns via line management or local operational escalation processes. More formal escalation processes such as Freedom To Speak Up (FTSU) policies and mechanisms should be followed as required. Within these, all staff should feel safe and empowered to raise concerns, supported by a culture and leadership that create psychological safety for everyone. 

In this context, the below should be considered: 

In all instance any concerns should be reported to the Practice Manager. 

2.13 Example list of the core responsibilities of the chaperone