- Introduction
- Policy Statement
CMK Medical Centre GP Practice is committed to providing a safe, respectful and dignified environment for patients and staff. All patients will routinely be offered a chaperone, ideally at the time of booking their appointment.
Where necessary, a chaperone will be provided to safeguard both patients and clinicians during intimate examinations or procedures. This policy aligns with:
- Care Quality Commission (CQC) GP Mythbuster 15: Chaperones
- NHS England guidance: Improving Chaperoning Practice in the NHS: Key Principles and Guidance
- General Medical Council (GMC) guidance on intimate examinations and consent
The Practice will ensure awareness of the chaperone policy through:
- Displayed posters in waiting and clinical areas
- Practice leaflets
- The Practice website
- Status
In accordance with the Equality Act 2010, CMK Medical Centre GP Practice has considered how this policy may affect different groups and individuals.
This policy and associated procedures are non-contractual and may be amended or withdrawn at any time. The policy applies to all employees, contractors, locums, trainees and temporary staff working within the Practice.
- Policy
- Who Can Act as a Chaperone
Any appropriately trained member of staff may act as a chaperone at CMK Medical Centre GP Practice.
All staff must complete chaperone awareness training. Staff undertaking the formal chaperone role must complete additional appropriate training in line with CQC guidance.
- General Guidance
The GMC advises that patients should be offered the option of having an impartial observer (chaperone) present whenever possible during intimate examinations or procedures.
Relatives or friends of the patient are not considered impartial observers and would not usually be suitable as formal chaperones. However, the Practice will comply with reasonable requests for a relative or friend to be present in addition to a formal chaperone.
Clinicians must ensure:
- Appropriate explanation of the examination or procedure
- Valid consent is obtained
- Patient dignity and privacy are maintained
- Chaperone details are documented in the patient’s clinical record
- Role and Expectations of a Chaperone
All staff acting as chaperones must adhere to relevant GMC and CQC guidance.
The role of the chaperone includes:
- Providing reassurance and support to the patient
- Assisting the clinician when appropriate
- Observing the examination or procedure
- Protecting both patient and clinician from misunderstanding or allegations
A chaperone does not replace the need for:
- Respectful communication
- Clear explanation
- Appropriate consent
- Professional conduct
- When a Chaperone is Unavailable
If either the clinician or the patient does not wish the examination to proceed without a chaperone present, or if there are concerns regarding the suitability of the available chaperone, the examination may be delayed until a suitable chaperone is available, provided this does not adversely affect the patient’s health or treatment.
- When a Patient Refuses a Chaperone
If a patient declines a chaperone but the clinician feels one is necessary, the clinician must explain the reasons clearly and sensitively.
Where appropriate, the clinician may:
- Rearrange the appointment
- Offer an alternative clinician
- Refer the patient to a colleague willing to proceed without a chaperone
The patient’s clinical needs must remain the primary consideration.
All discussions and outcomes must be documented in the patient’s record, including:
- That a chaperone was offered
- Whether the offer was accepted or declined
- The name and role of the chaperone where applicable
- Disclosure and Barring Service (DBS) Checks
Clinical staff acting as chaperones will already hold appropriate DBS clearance.
Where non-clinical staff undertake chaperone duties, the Practice will determine whether a DBS check is required based on the nature of the role and level of patient contact.
Where a DBS check is not undertaken, a documented risk assessment and rationale must be completed.
- Using Chaperones During Video Consultations
Although many intimate examinations are unsuitable for video consultation, where such consultations are undertaken the clinician must follow current CQC guidance regarding remote chaperoning.
The patient should be informed about:
- The role of the chaperone
- Who is present during the consultation
- Any limitations associated with remote examinations
Documentation requirements remain the same as for face-to-face consultations.
- Home Visits and Chaperones
Patients should be offered a chaperone in advance of any home visit involving an intimate examination where possible.
Where a chaperone cannot be arranged, clinicians must:
- Clearly explain the situation to the patient
- Obtain agreement to proceed
- Thoroughly document the rationale and discussion in the patient record
- Vulnerable Patients
Where patients may lack capacity or are otherwise vulnerable, clinicians must use professional judgement and act in the patient’s best interests.
The Practice will make reasonable adjustments where required to support vulnerable patients and ensure dignity, understanding and safeguarding.
- Children and Young People Under 18 Years
Any intimate examination involving a child or young person under 18 years must be carried out in the presence of a formal chaperone.
A parent, guardian, carer or trusted adult may also be present to provide reassurance.
Where the child or young person lacks capacity to consent, parents or carers must receive an appropriate explanation to enable informed consent to be obtained.
- Practice Procedure (Including SNOMED CT Codes)
Where a chaperone has not already been requested at the time of booking, the clinician will offer a chaperone prior to the examination or procedure.
The following procedure must be followed:
- Reception staff should be contacted to arrange a chaperone if required.
- The chaperone must be introduced to the patient.
- The chaperone should remain in a position where they can clearly observe the examination, usually near the patient’s head.
- The chaperone should maintain professional conduct at all times.
- Following the examination, the chaperone must document their presence and note any concerns or issues observed.
- The clinician must fully document the examination or procedure in accordance with the Practice medical records policy.
SNOMED CT Codes
| Detail | SNOMED CT ID |
| Requires chaperone | 1218711000000108 |
| Chaperone offered | 1104081000000107 |
| Patient agrees to chaperone | 1104081000000107 |
| Provision of chaperone refused | 763380007 |
| Chaperone not available | 428929009 |
| Presence of chaperone | 314229006 |
| Nurse chaperone | 314380009 |
- Escorting of Visitors and Guests (Including VIPs)
Where visitors, guests or VIPs attend the Practice, appropriate arrangements must be made to ensure they are escorted safely and appropriately in line with safeguarding and confidentiality requirements.
The Practice will follow relevant recommendations from the Lampard Report (2015).
Where there is likely to be media interest, the Practice Manager will notify the local Integrated Care Board (ICB) and seek communications support where appropriate.
Equality and Diversity Statement
CMK Medical Centre GP Practice is committed to promoting equality, diversity and inclusion in all aspects of service delivery and employment. This policy will be implemented fairly and consistently regardless of age, disability, gender reassignment, marriage or civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation.