1. What the regulation says
Service users must be treated with dignity and respect. (Regulation 10(1))
...having due regard to any relevant protected characteristics (as defined in section 149(7) of the Equality Act 2010) of the service user. (Regulation 10(2)(c))
The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/10. Where this policy and the regulation diverge, the regulation wins.
2. Plain-English summary
Service users must be treated with dignity and respect. In particular, you have to protect their privacy, support their autonomy, independence and involvement in the community, and have due regard to any relevant protected characteristics under the Equality Act 2010. For intimate, sensitive or distressing examinations and procedures, offering, recording and properly using a chaperone is one of the clearest ways a service protects dignity and privacy, evidences valid consent, and keeps both the person and the practitioner safe.
3. Purpose
The purpose of this policy is to protect the dignity, privacy, safety and rights of people using [Service Name] during intimate, sensitive or potentially distressing examinations, procedures or care.
A chaperone is not a formality. A chaperone helps support the person, protects dignity, provides reassurance, witnesses the process, and supports safe professional practice.
This policy supports Regulation 10 dignity and respect, Regulation 11 consent, Regulation 12 safe care and treatment, Regulation 13 safeguarding, Regulation 17 good governance and professional standards.
4. Policy warning
An intimate examination or procedure must not take place unless the person has given valid consent and has been offered a chaperone where appropriate.
Refusal of a chaperone must be respected, but the practitioner must consider whether it is safe and appropriate to proceed.
A family member or friend may support the person if the person wishes, but they should not normally replace a trained chaperone where a chaperone is clinically or professionally required.
5. Scope
This policy applies to:
- intimate examinations
- intimate procedures
- care involving exposure of breasts, genitalia, rectum or intimate areas
- sexual health examinations
- gynaecological examinations
- urological examinations
- rectal examinations
- breast examinations
- dermatology examinations involving intimate areas
- photography of intimate or sensitive areas
- procedures requiring undressing
- examinations where the person is distressed, vulnerable or anxious
- situations where power imbalance, communication difficulty or safeguarding risk is present
It applies regardless of the sex, gender, age or background of the person using the service.
6. Definitions
A chaperone is a trained person who is present during an examination, procedure or care episode to support the person, observe the process, help maintain dignity and provide a safeguard for the person and practitioner.
An intimate examination includes examination of breasts, genitalia, rectum or other intimate areas, and any examination that the person may reasonably experience as intimate, embarrassing, intrusive or distressing.
A support person is someone chosen by the person using the service, such as a relative, friend, advocate or carer. A support person is not automatically a trained chaperone.
7. Principles
The service will ensure that:
- people are treated with dignity and respect
- valid consent is obtained before examination or procedure
- chaperones are offered where appropriate
- refusal or acceptance of a chaperone is recorded
- chaperones are trained for the role
- privacy and modesty are protected
- explanations are given in plain language
- the person can pause or stop the examination
- concerns are escalated immediately
- records are accurate and complete
8. When a chaperone must be offered
A chaperone must be offered for:
- intimate examinations
- intimate procedures
- examinations requiring exposure of intimate areas
- sensitive photography
- procedures where the person may feel vulnerable
- examinations involving children or young people
- examinations involving adults who may lack capacity
- examinations involving people with communication difficulty
- examinations where there is known trauma, distress or safeguarding concern
- any situation where the practitioner, person or service considers a chaperone appropriate
The offer must be made in a way that the person can understand.
9. Consent
Before an intimate examination or procedure, the practitioner must explain:
- why the examination or procedure is needed
- what will happen
- what clothing may need to be removed
- who will be present
- the role of the chaperone
- the person's right to accept or decline the chaperone
- the person's right to ask questions
- the person's right to stop the examination
Consent must be voluntary, informed and specific to the examination or procedure.
If the person lacks capacity for the decision, the Mental Capacity Act process must be followed and the least restrictive option considered.
10. Refusal of chaperone
If the person declines a chaperone, the practitioner must record the offer and refusal.
The practitioner must consider whether to proceed. Factors to consider include:
- nature of examination
- vulnerability of the person
- communication needs
- safeguarding concerns
- professional guidance
- practitioner's own safety or professional concern
- whether another appointment can be arranged
- whether another practitioner should be present
- urgency of the examination
If the practitioner believes it is not safe or appropriate to proceed without a chaperone, they should explain this to the person and arrange an alternative unless urgent clinical need requires immediate action.
11. Request for a specific chaperone
The service will try to meet reasonable requests for a chaperone of a particular sex or gender where possible.
Where this cannot be arranged immediately, the person should be offered the option to wait or rebook where clinically safe.
The service must not discriminate or make assumptions about who needs a chaperone.
12. Children and young people
Children and young people must be offered privacy, dignity and appropriate support.
Where intimate examination or procedure is needed, the practitioner must consider:
- age and maturity
- Gillick competence where relevant
- parental responsibility
- safeguarding risk
- whether a parent or carer should be present
- whether a trained chaperone is also required
- the young person's wishes and feelings
- whether the examination is urgent or can be delayed
A parent or carer may support the child or young person, but the practitioner must consider whether a trained chaperone is also needed.
Any safeguarding concern must be escalated immediately.
13. Adults who may lack capacity
Where an adult may lack capacity to consent to the examination or procedure, the practitioner must follow the Mental Capacity Act. The record must show:
- the decision being considered
- capacity assessment
- how the person was supported to decide
- best-interests decision if they lack capacity
- people consulted
- least restrictive option
- whether the examination is necessary
- whether a chaperone was present
- how distress or objection was assessed
If the person objects or appears distressed, the practitioner must stop and reassess unless there is an immediate serious risk that requires urgent action.
14. Intimate examinations under sedation or anaesthesia
Where an intimate examination or procedure may take place while the person is sedated, anaesthetised or otherwise unable to give or confirm consent at the time, the practitioner must make sure that valid consent has been obtained beforehand for all relevant aspects of the examination or procedure.
The record must show what was explained, what was agreed, whether a chaperone was required or present, and any limits placed by the person.
An intimate examination must not be carried out for teaching, training or assessment purposes unless this has been specifically explained and the person has given explicit consent, recorded in writing or clearly documented in the clinical record.
The person's privacy and dignity must be protected even when they are sedated, anaesthetised or unable to participate actively.
15. Role of the chaperone
The chaperone must:
- be present for the relevant part of the examination or procedure
- understand what is being done and why
- support the person's dignity and privacy
- observe whether the person appears distressed or withdraws consent
- raise concerns if the examination appears inappropriate or unsafe
- help with practical support where trained and appropriate
- maintain confidentiality
- record or confirm their presence where required
The chaperone must not simply wait outside the room or act as an unrelated assistant.
16. Who may act as chaperone
A chaperone should normally be a trained member of staff. The chaperone must:
- understand the role
- have completed chaperone training
- understand confidentiality
- understand safeguarding escalation
- feel able to challenge the practitioner if concerned
- not have a conflict of interest
- not be under pressure to remain silent
A family member, friend or interpreter may support the person, but should not normally replace a trained chaperone.
17. Privacy and dignity
The practitioner and chaperone must protect privacy and dignity by:
- using a private room or screened area
- closing doors or curtains
- minimising exposure
- providing covering or drape where appropriate
- explaining each step before it happens
- allowing the person to undress and dress in privacy
- keeping conversation respectful
- avoiding unnecessary people in the room
- stopping if the person asks or appears distressed
18. Recording
The clinical or care record must show:
- that a chaperone was offered
- whether the person accepted or declined
- name and role of chaperone if present
- name of support person if present
- explanation given
- consent obtained
- any communication or capacity needs
- any distress, objection or pause
- any concern raised
- outcome of examination or procedure
- reason if the examination proceeded without a chaperone where one would normally be expected
The record must be factual and contemporaneous.
19. Concerns during or after examination
If the chaperone, practitioner, person using the service, family member or staff member has concerns about the conduct or appropriateness of an examination, they must raise this immediately. Concerns may require:
- stopping the examination
- checking the person's safety and wellbeing
- informing the Registered Manager
- safeguarding referral
- professional-regulator referral
- police contact
- incident record
- complaint process
- duty of candour consideration
- CQC notification consideration
The service must not dismiss concerns because a chaperone was present.
20. Chaperone training
Staff acting as chaperones must receive training covering:
- purpose of chaperoning
- consent
- dignity and privacy
- intimate examinations
- safeguarding
- confidentiality
- professional boundaries
- how to challenge concerns
- record keeping
- supporting people with communication needs
- supporting children, young people and adults who may lack capacity
- escalation routes
Training must be recorded and refreshed at intervals set by the service.
21. Availability of chaperones
The service must plan for chaperone availability.
Where intimate examinations or procedures are part of routine service delivery, the rota or appointment system must ensure that a trained chaperone is available.
If a chaperone is not available and the examination is not urgent, the person should be offered the option to wait or rebook. Where the examination is urgent, the practitioner must record why it proceeded and what safeguards were used.
22. Audit
The Registered Manager must audit chaperone records at least annually, or more often where the service frequently undertakes intimate examinations or procedures. The audit must check:
- whether chaperones were offered
- whether acceptance or refusal was recorded
- whether chaperone names and roles were recorded
- whether consent was recorded
- whether capacity issues were documented
- whether staff had chaperone training
- whether any concerns were raised
- whether privacy and dignity standards were met
Findings must be actioned through the governance process.
23. Related policies in this pack
This policy should be read with:
- Consent Policy
- Dignity and Respect Policy
- Safeguarding Adults Policy
- Safeguarding Children Policy
- Mental Capacity Act Policy
- Record Keeping and Documentation Standards Policy
- Complaints Policy
- Incident Reporting, Investigation and Learning Policy
- Staff Conduct and Disciplinary Policy
- Professional Boundaries and Conduct Policy
- Equality and Diversity Policy
- Data Protection and Confidentiality Policy
24. Review
This policy will be reviewed annually, or sooner following a complaint, safeguarding concern, incident, CQC finding, professional-regulatory concern, change in clinical practice, or change in legal or professional guidance.
25. Sources and further reading
This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.
- CQC Regulation 10: Dignity and respect
- CQC Regulation 11: Need for consent
- CQC Regulation 13: Safeguarding service users from abuse and improper treatment
- CQC Regulation 17: Good governance
- GMC: Intimate examinations and chaperones
- Mental Capacity Act 2005 (https://www.legislation.gov.uk/ukpga/2005/9)
- Human Rights Act 1998 (https://www.legislation.gov.uk/ukpga/1998/42)
- Equality Act 2010 (https://www.legislation.gov.uk/ukpga/2010/15)
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/10)
26. When to seek further advice
Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.
27. Document control
| Version | Date | Author | Changes |
|---|---|---|---|
| v1 | 2026-06-10 | Verivius (sample) | Initial sample template, conformed to the Verivius policy standard. |
This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.