Headstone Road Surgery

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Chaperones policy

The Surgery prides itself in maintaining professional standards. For certain examinations during consultations an impartial observer (a “Chaperone”) will be required.

This impartial observer will be a Practice Nurse or Health Care Assistant who is familiar with the procedure and be available to reassure and raise any concerns on your behalf. If a nurse in unavailable at the time of your consultation then your examination may be re-scheduled for another time.

You are free to decline any examination or chose an alternative examiner or chaperone. You may also request a chaperone for any examination or consultation if one is not offered to you. The GP may not undertake an examination if a chaperone is declined.

The role of a Chaperone:

  • Maintains professional boundaries during intimate examinations.
  • Acknowledges a patient’s vulnerability.
  • Provides emotional comfort and reassurance.
  • Assists in the examination.
  • Assists with undressing patients, if required.

1 Introduction

1.1 Policy statement

The purpose of this document is to ensure conformity in order to achieve a common standard of medical Practice. This is achieved by enabling the patient to have a chaperone present during the consultation and clinical examination of the patient. Medical examinations can, at times, be perceived as intrusive by the patient so having a chaperone present protects both the patient and staff member.

1.2 Status

This document and any procedures contained within it are non-contractual and may be modified or withdrawn at any time. For the avoidance of doubt, it does not form part of your contract of employment.

1.3 Training and support

Headstone Road Surgery will provide guidance and support to help those to whom it applies to understand their rights and responsibilities under this policy. Additional support will be provided to managers and supervisors to enable them to deal more effectively with matters arising from this policy.

2 Scope

2.1 Who it applies to

This document applies to all employees of Headstone Road Surgery. Other individuals performing functions in relation to the organisation, such as agency workers, locums and contractors, are encouraged to use it.

2.2 Why and how it applies to them

It is a requirement that, where necessary, chaperones are provided to protect and safeguard both patients and clinicians during intimate examinations and or procedures.[1]

All clinical staff may at some point be asked to act as a chaperone at Headstone Road Surgery. Therefore, it is essential that clinical personnel are fully trained and aware of their individual responsibilities when performing chaperone duties.

The organisation aims to design and implement policies and procedures that meet the diverse needs of our service and workforce, ensuring that none are placed at a disadvantage over others, in accordance with the Equality Act 2010. Consideration has been given to the impact this policy might have with regard to the individual protected characteristics of those to whom it applies.

3 Definition of terms

3.1 Chaperone

A chaperone can be defined as ‘an independent person, appropriately trained, whose role is to observe independently the examination/procedure undertaken by the doctor/health professional to assist the appropriate doctor-patient relationship’.[2]

The term implies that the person may be a healthcare professional. However, it can also mean a specifically trained non-clinical staff member.

See CQC Nigel’s surgery 15

4 Policy

4.1 Raising patient awareness

At Headstone Road Surgery, a chaperone poster is clearly displayed in the waiting area, in all clinical areas and annotated in the Practice leaflet as well as on the Practice website.

All patients should routinely be offered a chaperone, ideally at the time of booking the appointment and the importance of a chaperone should not be underestimated or understated.

4.2 Personnel authorised to act as chaperones

It is policy that any member of the Practice team can act as a chaperone provided that they have undertaken appropriate chaperone training. If a chaperone is not available, the examination should be postponed until a suitable chaperone is present.

Patients must be advised that a family member or friend is not permitted to act as a chaperone as they are not deemed to be impartial even if they have the requisite training or clinical knowledge. However, they may be present during the procedure/examination if the patient is content with this decision.

4.3 General guidance

It may be appropriate to offer a chaperone for a number of reasons. All clinicians should consider using a chaperone for some or all of the consultation and not solely for the purpose of intimate examinations or procedures. This applies whether the clinician is of the same gender as the patient or not.

Before conducting any intimate examination, the clinician must obtain the patient’s consent and:[3]

  • Explain to the patient why an examination is necessary and give the patient an opportunity to ask questions
  • Explain what the examination will involve, in a way the patient can understand, so that the patient has a clear idea of what to expect, including any pain or discomfort
  • Get the patient’s consent before the examination and record that the patient has given it
  • Offer the patient a chaperone
  • Give the patient privacy to undress and dress, and keep them covered as much as possible to maintain their dignity. Do not help the patient to remove clothing unless they have asked you to do so, or you have checked with them that they want you to help

If the patient is a young person or child, you must:

  • Assess their capacity to consent to the examination
  • Seek parental consent if they lack capacity,

Ensuring that the patient fully understands the why, what and how of the examination process should mitigate the potential for confusion.

4.4 The role of the chaperone

The role of the chaperone varies on a case-by-case basis, taking into consideration the need of the patient and the examination or procedure being carried out. A chaperone is present as a safeguard for all parties and is an impartial witness to continuing consent of the examination or procedure.

Expectations of chaperones are listed in the GMC guidance. It states chaperones should:

  • Be sensitive and respect the patient’s dignity and confidentiality
  • Reassure the patient if they show signs of distress or discomfort
  • Be familiar with the procedures involved in a routine intimate examination
  • Stay for the whole examination and be able to see what the doctor is doing, if practical
  • Be prepared to raise concerns if they are concerned about the doctor’s behaviour or actions

In addition, the chaperone may be expected to:

Act as an interpreter

  • Provide emotional comfort and reassurance to patients
  • Assist in the examination (handing equipment to clinicians)
  • Assist with undressing or dressing the patient, but only should a patient require assistance
  • Provide protection for the clinician (against unfounded allegations or attack)
  • Witness the procedure (ensuring that it is appropriately conducted)

4.5 Competencies and training

Chaperones should undergo training which enables them to understand:

  • What is meant by the term ‘chaperone’
  • What an ‘intimate examination’ is
  • A knowledge of the range of examinations or procedures they may be expected to witness
  • Why they need to be present, including positioning inside the screened-off area
  • Their role and responsibilities as a chaperone. Note that it is important that chaperones place themselves inside the screened-off area rather than outside of the curtains/screen (if outside, they are then not technically chaperoning)
  • How to raise concerns in conjunction with Practice policy
  • The rights of the patient
  • The requirement to annotate their presence on the individual’s healthcare record post consultation

Training will be undertaken by all staff who may be required to act as a chaperone at Headstone Road Surgery.

In addition to training, employees conducting chaperone duties are to be in receipt of a DBS certificate.

4.6 Disclosure and Barring Service Certificate

To act as a chaperone, staff who undertake this role must have a Disclosure and Barring Service (DBS) Certificate. This is further supported and is detailed in CQC Nigel’s Surgery 2.

Whilst clinical staff who undertake this role will already have a DBS check, non-clinical staff will also need a DBS check in order to act as a chaperone due to the nature of chaperoning duties and the level of patient contact.

4.7 Considerations

In a diverse multicultural society, it is important to acknowledge the spiritual, social and cultural factors associated with the patient population. Clinicians must respect the patient’s wishes and, where appropriate, refer them to another practitioner to have the examination or procedure undertaken.

Local guidance should be sought regarding patients suffering from mental illness or those with learning difficulties. A relative or carer will prove to be a valuable adjunct to a chaperone.

4.8 Confidentiality

Chaperones are to ensure that they adhere to the Caldicott and information governance policies. The clinician carrying out the examination or procedure should reassure the patient that all clinical staff within the Practice fully understand their obligation to maintain confidentiality at all times.

4.9 Using chaperones during a video consultation

See extract from CQC Nigel’s surgery 15

Many intimate examinations will not be suitable for a video consultation. Where online, video or telephone consultations take place, GMC guidance explains how to protect patients when images are needed to support clinical decision making. This includes appropriate use of photographs and video consultations as part of patient care.

Where intimate examinations are performed it is important that a chaperone is offered. Documentation should clearly reflect this. It is important to document who provided the chaperoning. It should also state what part of the consultation they were present for. For further advice on audio and video consultations, plus the management of any imagery.

4.10 Practice procedure (including SNOMED codes)

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

Detail and SNOMED CT Code[4]

  • The patient agrees to a chaperone 1104081000000107
  • Refusal to have a chaperone present 763380007
  • No chaperones available 428929009

4.11 Escorting of visitors and guests (including VIPs)

There may be, on occasion, a need to ensure that appropriate measures are in place to escort visitors and guests including Very Important People (VIPs). Headstone Road Surgery will follow the recommendations outlined in the Lampard Report (2015)[5]:

  • Ensure that any visitors are escorted by a permanent member of staff at all times throughout the duration of their visit
  • The individual organising the visit must arrange for a suitable member of staff to act as an escort. Furthermore, the reason for the visit must be documented, giving details of the areas to be visited and if patients are to be contacted during the visit
  • The escort is to ensure that no visitors enter clinical areas where there may be intimate examinations or procedures taking place. This protects and promotes the privacy, dignity and respect of patients
  • The person arranging the visit must ensure that there is sufficient time for the Practice team to advise patients of the visit and offer patients the opportunity to decline to interact with the visitor(s)
  • Given the diverse nature of the patient population, some patients may not understand or may become confused as to why visitors or guests (including VIPs) are present. To minimise any confusion or distress, such patients as well as the visitor(s) are to be offered an escort
  • The person arranging the visit must ensure that the visitor(s) has produced photographic ID prior to the visit taking place
  • The escort is to accept responsibility for the visitor(s) at all times. They must also be prepared to challenge any unacceptable or inappropriate behaviour, reporting such incidences to the Practice manager immediately.
  • The escort must ensure that no patient records or other patient-identifiable information is disclosed to the visitor(s). Escorts are to ensure that the visitor(s) is aware of the need to retain confidentiality should they overhear clinical information being discussed. Any breaches of confidentiality are to be reported immediately to the Practice manager
  • If media interest is likely, the Practice manager is to inform Harrow CCG, requesting that the communication team provides guidance
  • Under no circumstances is the escort to leave the visitor(s) alone with any patient or patient-identifiable information. This is to ensure that both the patient and visitor(s) are appropriately protected

4.12 Summary

The relationship between the clinician and patient is based on trust and chaperones are a safeguard for both parties at Headstone Road Surgery.

The role of a chaperone is vital in maintaining a good standard of Practice during consultations and examinations. Regular training for staff and raising patient awareness will ensure that this policy is maintained.

[1] CQC Guidance Nigel’s Surgery 15: Chaperones

[2] GMC Ethical Guidance Intimate examination and chaperones

[3] NHS England Consent to treatment

[4] SNOMED CT Browser

[5] Lampard Report (2015)

Date published: 23rd March, 2023
Date last updated: 4th April, 2023