Bell House Medical Centre

 

Part of Medics PCN

We aim to make people feel better        

NHS Logo

Chaperones

Introduction

This policy sets out BELL HOUSE MEDICAL CENTRE’s approach to the use of chaperones during clinical consultations and examinations. It is designed to safeguard patients and staff, promote dignity and respect, and support informed patient choice.

A chaperone will be offered for all intimate examinations. A chaperone may also be offered for consultations involving sensitive or personal matters. Patients may request a chaperone at any time.

Scope

This policy applies to all clinical staff working within BELL HOUSE MEDICAL CENTRE, including doctors, nurses, healthcare assistants, and any other staff involved in patient care, whether delivered in practice premises, treatment centres, or patients’ homes.

It also applies to non-clinical staff who have been trained and authorised to act as chaperones.

Policy Statement

BELL HOUSE MEDICAL CENTRE is committed to ensuring that patients are aware of their right to request a chaperone and that appropriate arrangements are made where required.

A chaperone must be offered for all intimate examinations. The offer and the patient’s decision must be clearly recorded in the clinical record.

Patients must not be examined without a chaperone where one has been requested. Where a chaperone is not available and the examination is not urgent, the consultation or examination should be rearranged.

Regulatory Expectations

BELL HOUSE MEDICAL CENTRE will meet national professional and regulatory expectations in relation to chaperoning during consultations and examinations.

The practice will:

  • Ensure patients are aware of their right to request a chaperone
  • Make chaperone information clearly visible in waiting areas and consulting or treatment rooms
  • Provide chaperone information through public-facing materials such as the practice website and leaflet
  • Ensure chaperones are appropriate, trained, and understand their role
  • Record the offer, acceptance, or refusal of a chaperone, including the chaperone’s identity
  • Maintain dignity, consent, confidentiality, and safeguarding throughout

Safeguarding Considerations

  • Chaperoning is an important safeguarding measure for both patients and staff.
  • A chaperone must always be offered for intimate examinations of children, young people and adults at risk.
  • The presence of a parent or carer does not replace the need for a formal chaperone where appropriate.
  • Any safeguarding concern identified by the clinician or chaperone must be escalated immediately in line with the Practice’s safeguarding procedures.
  • Capacity, consent and best‑interest principles must be followed in accordance with national safeguarding guidance.

This approach aligns with the expectations of both the Care Quality Commission (CQC) and Health Inspectorate Wales (HIW), and with national professional guidance.

England‑specific requirement

This policy aligns with national professional guidance, including the General Medical Council’s guidance on intimate examinations and chaperones, the Royal College of Nursing’s standards, and NHS England’s sexual safety and chaperoning principles. It reflects the strengthened requirements introduced through NHS England’s Sexual Safety Charter programme, including the expectation that GP practices in England evidence compliance by March 2026.

Information for Patients

Patients will be informed of their right to request a chaperone through:

  • Clear signage in waiting areas and consulting or treatment rooms
  • Information included on the practice website
  • Information included in the practice leaflet
  • Information provided by staff where appropriate, including at the point of booking or prior to an examination

When a Chaperone Should Be Considered

Clinicians must offer a chaperone for all intimate examinations.

A chaperone should also be considered where:

  • The consultation involves sensitive or personal matters
  • Either the patient or clinician feels uncomfortable
  • There is a potential risk of misunderstanding

The need for a chaperone applies regardless of the gender of the patient or clinician.

Patient preferences relating to gender, cultural background or communication needs will be respected wherever reasonably practicable.

Documentation Requirements

The clinical record must clearly document:

  • That a chaperone was offered
  • Whether the offer was accepted or declined
  • The name and role of the chaperone (if present)
  • Any relevant patient preference
  • Any concerns raised

Where a patient declines a chaperone, this must be recorded.

Who Can Act as a Chaperone?

Chaperones must:

  • Be trained in the role and responsibilities of chaperoning
  • Understand dignity, consent, confidentiality, and professional boundaries
  • Be confident in raising concerns if required

Where possible, chaperones should be clinical staff familiar with examination procedures. Where non-clinical staff act as chaperones, the patient’s agreement must be obtained.

All staff acting as chaperones must have appropriate DBS clearance.

Responsibilities of the Clinician

The clinician must:

  • Explain the examination clearly and sensitively
  • Offer a chaperone where required
  • Obtain and record the patient’s consent or refusal
  • Ensure privacy for undressing and dressing
  • Maintain a professional and respectful manner

Clinicians must be aware of safeguarding responsibilities and escalate any concerns immediately in line with the Practice’s safeguarding procedures.

If a patient declines a chaperone that the clinician considers necessary, the clinician should explain their reasons and may offer an alternative clinician or rearranged appointment where this would not adversely affect the patient’s health.

Safeguarding Considerations

Chaperoning is an important safeguarding measure for both patients and staff. All staff must remain alert to signs of abuse, coercion, neglect or inappropriate behaviour during consultations or examinations. Any safeguarding concern identified by the clinician or chaperone must be escalated immediately in line with the Practice’s safeguarding procedures.

A chaperone must always be offered for intimate examinations of children, young people and adults at risk. The presence of a parent or carer does not replace the need for a formal chaperone where appropriate. Capacity, consent and best‑interest principles must be followed in accordance with national safeguarding guidance.

Responsibilities of the Chaperone

The chaperone must:

  • Be present for the examination only
  • Position themselves so they are able to observe the examination while maintaining the patient’s dignity and privacy
  • Ensure the patient’s dignity and privacy are maintained
  • Not participate in the consultation unless requested
  • Maintain confidentiality at all times

Chaperones must be aware of safeguarding responsibilities and escalate any concerns immediately in line with the Practice’s safeguarding procedures.

The chaperone must record their attendance and any concerns or incidents in line with practice procedures.

Procedure for Using a Chaperone

  1. The clinician identifies the need for, or receives a request for, a chaperone.
  2. Appropriate staff are contacted to arrange a trained chaperone.
  3. The patient’s consent is confirmed.
  4. The chaperone attends discreetly and remains present for the examination.
  5. The clinician records the chaperone’s name and role in the clinical record.
  6. The chaperone documents their attendance and any concerns, if applicable.

Where a chaperone is unavailable and delay would not adversely affect the patient’s health, the examination should be rescheduled.

Home Visits

Where an intimate examination is anticipated during a home visit, consideration should be given to the need for a chaperone. The same principles of consent, documentation, dignity, and professional conduct apply.

Clinicians undertaking home visits must also follow the Practice’s lone working procedures.

Remote Consultations

Where an intimate examination is required during a remote consultation, clinicians must follow national guidance to ensure appropriate safeguards are in place. Intimate examinations should not be undertaken remotely unless safe, appropriate, and in line with professional guidance.

Confidentiality

The chaperone should only be present for the examination itself. Most discussion with the patient should take place while the chaperone is not present.

Patients should be reassured that all practice staff understand their responsibility not to divulge confidential information.

Concerns, Complaints and Allegations

Any concerns raised by a chaperone, clinician, or patient must be reported in line with the Practice’s incident reporting, safeguarding, or complaints procedures.

Staff involved will be supported appropriately while concerns are investigated.

Training and Review

Staff undertaking chaperone duties will receive formal training covering dignity, consent, safeguarding, professional boundaries and documentation requirements. Training will be refreshed periodically, or sooner if guidance changes.

This policy will be reviewed periodically or sooner if national guidance or regulatory expectations change.

Other Uses for a Chaperone

There are occasions where, due to the patient’s history or previous incidents, a clinician may request a chaperone for the duration of a consultation. The patient must be informed, and the chaperone’s presence and role must be recorded in the clinical record.

FURTHER INFORMATION

Related Guidance