Chaperone Policy

 

1. Purpose

This policy outlines the Practice’s approach to the use of Chaperones during examinations and consultations. It aims to protect both patients and staff from abuse or allegations of abuse, and to promote a safe, respectful, and professional environment.

The policy is based on the latest guidance from the General Medical Council (GMC) – Intimate Examinations and Chaperones (2024), the Care Quality Commission (CQC) standards, and NHS England safeguarding policies.

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2. Policy

All patients have the right to dignity, privacy, and safety during medical examinations. The Practice is committed to ensuring that:

• Patients understand their right to request a Chaperone.

• Examinations are explained clearly and conducted with informed consent.

• Staff and patients are protected from potential misunderstanding or allegations.

• Appropriate records are made whenever a Chaperone is involved.

 

3. Procedure

3.1 When a Chaperone May Be Required

A Chaperone should be offered in any situation where an examination or procedure might be considered intimate or where either the clinician or patient feels it appropriate. This includes:

• Examinations of the breasts, genitalia, or rectal area.

• Procedures involving the removal of clothing or physical contact.

• Circumstances where the patient or clinician may feel vulnerable or uncomfortable.

• Home visits that may involve an intimate examination.

 

This also applies to telephone and online consultations, for example when intimate virtual examinations are required, when intimate images are shared or in any circumstances where the patient or clinician may feel vulnerable or uncomfortable.

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3.2 Patient Information and Consent

Information about the availability of Chaperones is displayed clearly in each consulting room.

Patients should be informed that:

• They may request a Chaperone at any time.

• A Chaperone can be present for any consultation, not only intimate examinations.

• They may decline a Chaperone if they prefer, although in some cases the clinician may decide that it is inappropriate to proceed without one.

Verbal consent for both the examination and the presence of a Chaperone must always be obtained and documented in the patient record. The clinician will always explain why an examination is necessary and what it will involve before seeking consent to proceed.

If the patient cannot make an informed decision, the clinician must use their clinical judgement and be able to justify their course of action. 

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3.3 Who Can Act as a Chaperone

A Chaperone may be a member of the clinical or non-clinical team.  As a small practice, in most instances, the chaperone will be one of the receptionists.  To act as a chaperone, the staff member must:

• Have completed Chaperone and safeguarding training.

• Be DBS-checked.

• Understand the boundaries and responsibilities of the role.

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3.4 The Role of the Chaperone

The Chaperone’s primary responsibility is to act as a safeguard for both the patient and the clinician. They provide reassurance, assist in maintaining dignity, and ensure that professional standards are upheld.

During an examination, the Chaperone should:

• Enter the room discreetly and remain until the examination is complete.

• Stand where the patient requests - this can be inside the curtain with visibility to observe the examination appropriately, or outside the curtain.

• Remain alert to the conduct of the examination and the patient’s comfort.

• Avoid unnecessary conversation during the procedure.

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3.5 Home Visits

A chaperone is unlikely to be available for a home visit. If an intimate examination is required during a home visit:

• The clinician should assess the risks and discuss options with the patient.

• If the examination must proceed, the patient’s consent and the absence of a Chaperone must be clearly documented.

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3.6 Children and young people under 18

Any intimate examination on children and young people under 18 years should be carried out in the presence of a 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. 

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3.7 Considerations

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.

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3.8 If a chaperone is not available

If no trained Chaperone is available, the examination should be deferred unless this would negatively affect the patient’s care.

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3.9 If a patient declines a chaperone

Patients have the right to decline a chaperone for any reason, including personal, cultural or privacy concerns, the presence of a family member or carer, or because they do not feel it is necessary. Staff must respect this decision while ensuring the patient’s safety and dignity.

If a clinician believes that proceeding without a chaperone would compromise professional standards or patient safety, they should risk assess and the examination should be postponed until an appropriate chaperone is available. The rationale for deferral must be clearly documented in the patient’s record.

When a chaperone is declined, staff should document the discussion and decision.

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3.10 Confidentiality

Chaperones are bound by the same duty of confidentiality as all practice staff. They should only be present during the examination itself, unless their presence is specifically requested for discussion.

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3.11 Documentation

The clinician must make a clear record of:

• The explanation provided to the patient.

• The patient’s decision - consent or refusal.

• The presence of a Chaperone, including their name and role or if no chaperone present, explain why this was declined

• Any concerns, incidents, or refusals.

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3.12 Raising concerns

Patients can raise any concerns both during the examination and subsequently. Concerns can be raised to the chaperone, the clinician, another member or staff or by following our complaints procedure, available on our website.

Staff have a duty of care to raise concerns regarding inappropriate behaviour, unlawful conduct, poor practice or behaviour. Staff can raise any concerns both during the examination and subsequently.  Concerns can be raised to the clinician, another member of staff, their line manager, the senior management or CQC.  Staff should refer to the Whistleblowing policy.

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4. Responsibilities

Victoria Thomas, Practice Manager, is responsible for this policy, ensuring its implementation and assuring quality and safety governance.

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