Purpose and Scope

This policy sets out how Sketty & Killay Surgeries will offer and use chaperones to safeguard patients and clinicians during consultations, examinations, investigations, and procedures—especially intimate examinations. It applies to all clinicians and non-clinical staff, all patients (adults and children), and all settings where care is delivered by the practice.

Wales

Health Inspectorate Wales (HIW) expect that Chaperone Posters are clearly displayed in the waiting room and in each Consulting Room as well as on the Practice Leaflet and Website to make patients aware they may request a Chaperone.

Definitions

• Intimate examination: Any examination where it is necessary to touch or view the breasts, genitalia, or rectum, or where the nature of the examination may be perceived as intimate by the patient.
• Chaperone: An impartial, trained member of staff present to provide reassurance and support to the patient, to observe the conduct of the examination, and to support clinical staff. A friend or relative may be present for support but is not usually a suitable chaperone.

Guidelines

Clinicians (male and female) should consider whether an intimate or personal examination of the patient (either male or female) is justified, or whether the nature of the consultation poses a risk of misunderstanding.

• The clinician should give the patient a clear explanation of what the examination will involve.
• Always adopt a professional and considerate manner - be careful with humour as a way of relaxing a nervous situation as it can easily be misinterpreted.
• Always ensure that the patient is provided with adequate privacy to undress and dress.
• Ensure that a suitable sign is clearly on display in each consulting or treatment room offering the chaperone service.
• Dignity & respect: Privacy, dignity, cultural and religious considerations, and language needs will be respected at all times.

This should remove the potential for misunderstanding. However, there will still be times when either the clinician, or the patient, feels uncomfortable, and it would be appropriate to consider using a chaperone.

Patients who request a chaperone should never be examined without a chaperone being present. If necessary, where a chaperone is not available, the consultation/examination should be rearranged for a mutually convenient time when a chaperone can be present.

Who Can Act as a Chaperone?

• Preferred: A clinician or trained practice staff member who has completed chaperone training and understands their role.
• Not usually suitable: Family members or friends (support persons) are not impartial observers and therefore do not normally act as the formal chaperone, though they may accompany the patient for support.

Offering, Arranging, and Recording a Chaperone

• Reception and clinical staff will inform patients (when booking, on arrival, and again before examination) that a chaperone is available.
• If a patient requests a particular chaperone gender, we will accommodate where practicable or rebook if clinically appropriate.

Key Actions for Chaperones

• Obtain the patient’s consent to have a Chaperone before the examination and record that it has been received in the patient’s notes.
• Follow relevant policies and procedures where there are issues relevant to patient capacity.
• Chaperone must give the patient privacy to undress and dress using drapes, screens, blankets always.
• Record the use of and the identity of the chaperone in the patient’s notes: use the Chaperone stamp when using paper records.
• Ensure the patient is always supported to dress fully after the procedure maintaining his/her full dignity and privacy.

Confidentiality

• The chaperone should only be present for the examination itself, and 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.

Procedure

• The clinician will contact reception to request a chaperone.
• Where no chaperone is available, a clinician may offer to delay the examination to a date when one will be available, as long as the delay would not have an adverse effect on the patient’s health.

Documentation (recorded in the clinical record):

• That a chaperone was offered and accepted/declined.
• Name and role of the chaperone (if present).
• Brief description of the examination and any issues/concerns raised.
• If a patient declines and the clinician proceeds, the reason must be documented. If the clinician considers a chaperone essential and none is available, the exam should be deferred unless urgent.
• The chaperone themselves must also add a clinical note that they have acted as a chaperone along with the clinician’s name

During the Examination – Chaperone Responsibilities

The chaperone must:

• Position themselves to observe the examination while maintaining patient dignity.
• Provide reassurance, be alert to distress or discomfort, and speak up if concerned.
• Uphold confidentiality and understand the escalation route for safeguarding concerns.

Children, Young People, and Adults at Risk

• For patients under 16, a parent/guardian or appropriate adult should normally be present. A formal chaperone should still be offered and provided where appropriate.
• For competent young people who do not want a parent present, a chaperone should be offered and the decision recorded.
• For adults at risk or where capacity is in question, a chaperone will normally be offered as standard.

Language, Culture, and Accessibility

• If an interpreter is needed, this is in addition to (not instead of) a chaperone.
• Reasonable adjustments (e.g., longer appointments, accessible facilities) will be made to support disabled patients and those with sensory loss.

If a Chaperone is Requested but Unavailable

• The patient will be offered to wait until a trained chaperone becomes available or to rebook with a chaperone present, unless the examination is urgent.
• If the clinician deems a chaperone essential for safety and none is available, the examination should be deferred unless urgent. The decision must be documented.

Refusal or Concerns

• If a patient refuses a chaperone but the clinician considers one essential, the examination should normally be postponed and alternatives discussed. The refusal for a chaperone must be recorded in the patients notes
• Any concerns or complaints relating to a chaperoned (or un-chaperoned) examination must be escalated via the practice complaints and safeguarding procedures.

Lone Working, Home Visits & Remote Care

• For home visits or settings without other staff present, clinicians should consider risk and arrange for a chaperone where practicable or modify/defer intimate examinations if safe to do so.
• For remote consultations: examinations requiring physical contact should not be performed remotely; if sensitive discussions occur, clinicians should consider offering a chaperone present on site with the patient where feasible.

Training & Governance

• All staff who may act as chaperones will complete chaperone and safeguarding training at the appropriate level, refreshed at least every three years.
• Induction will cover this policy, role boundaries, documentation standards, confidentiality, and escalation of safeguarding concerns.
• Compliance (documentation of offer/use) will be audited annually and actions taken to improve.

Data Protection and Confidentiality

• Chaperones must maintain confidentiality at all times. Information will be recorded in line with data protection law and practice policies.

Equality Statement

Sketty & Killay Surgeries is committed to fair and equitable access to chaperones regardless of age, sex, gender identity, sexual orientation, disability, race, religion or belief, language, pregnancy/maternity, or socioeconomic status. Reasonable adjustments and language support will be provided.

Other Uses for a Chaperone

There are times when, because of past events and the history of the patient, a clinician wants a chaperone in the consultation. Again, the patient needs to be consulted and a chaperone to attend for the duration of the consultation. At the end of the consultation the chaperone should make an entry into the patient’s record.