Policy Statement

At Warley Road Surgery, 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.

 Who can act as a chaperone

At Warley Road Surgery, 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.

 Role and expectations of a chaperone

Staff at Warley Road Surgery 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 

 Home visits and chaperones

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. 

Children and young people under 18 years

NHS England guidance states that 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.