Chaperone Policy

Policy statement

At The Whitehorse Practice, 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.

At the practice, a chaperone poster is displayed in both waiting areas, 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 This document and any procedures contained within it are non-contractual, which means they may be modified or withdrawn at any time.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.

Who can act as a chaperone

At the practice, 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. All staff must complete chaperone awareness training which covers the role of the chaperone in addition to a DBS check.

General Guidance

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 medical record.

Role and expectations of a chaperone

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.

When a chaperone is unavailable

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.

When a patient refuses a chaperone

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:

• Who the chaperone was
• Their title
• That the offer was made and declined

Disclosure and Barring Service (DBS) check

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.

Video consultations

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.

Home visits

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.

Vulnerable patients

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.

Practice procedure

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

• Contact reception and request a chaperone
• Record in the individual’s healthcare record that a chaperone is present and identify them
• The chaperone should be introduced to the patient
• The chaperone should assist as required but maintain a position so that they are able to witness the procedure/examination (usually at the head end)
• The chaperone should adhere to their role at all times
• Post procedure or examination, the chaperone should ensure they annotate in the patient’s healthcare record that they were present during the examination and there were no issues observed
• The clinician will annotate in the individual’s healthcare record the full details of the procedure as per current medical records policy

Escorting visitors and guests

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.